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UNIFIED PROGRAM CONSOLIDATED FORM ,` Z4 UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-FACILITY INFORMATION (One form per facility) TYPE OF ACTION '1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION400. (Check one item only) ❑ 7.PERMANENT FACILITY CLOSURE ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# _ 1. (Agency Use Only) BUSINESS NAME(Same as FACILITY NAME or D(BA�-Doing Business As) ^-7 3 ai / BUSINESS SITE ADDPESSr 103, CITY 104. 15 AJ W654 FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING [1 2.FUEL DISTRIBUTION 403. Is the facility locatedon In Ian Reservation or 405. ❑ 3.FARM E] 4.PROCESSOR 6.OTHER F� .e- Trust lands? E]Yes No II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408. MAILING ADDRESS 409. 230 S-F. R"�L l CITY 410, STATE 411. ZIP CODE +Iz. 1 CA 9 III. TANK OPERATOR INFORMATION "TANK OPERATOR NAME 4ze-1. PHONE 428-2 J�' be ( ) MAILING ADDRESS 428-3 f'+7 �t CITY 4284 STATE 428-5 ZIP CODE 428-6 �ac-rgwle a IV. TANK OWNER INFORMATION TANK OWNER NAME 414, PHONE 415. B,,J &,, b ( ) MAILING ADDRESS 416. 5�-- ' CI an. STATE 418. ZIP CODE vv. cig (?<;69 OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420_ ❑ 7.FEDERAL AGENCY �I,8.NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK) HQ 44- 1 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421 VI.PERMIT HOLDER INFORMATION Issue ertnit and send legal notifications and mailings to: i23 p g g ❑ I.FACILITY OWNER ',�!4.TANK OPERATOR ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406- VII.APPLICANT SIGNATURE CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal re uirements. APPLICANT SIGNATURE DATE 424. PHONE 425. APPLICANT NAME(print) 426. APPLICANT TITLE 427 UPCF UST-A Rev.(12/2007)