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CL) <br /> UNIFIED PROGRAM CONSOIAIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> low fman per�flldf <br /> p <br /> TYPE OF ACTION 1.NEW PERMIT 5.CHANGE OF INFORMATION 0 7.PERMANENT FACILrfy CLOSURE <br /> I(Checkoneftemoub,) 3.RENEWAL PERMIT 0 6.TEMPORARY FACILITY CLOSURE 0 9.TRANSFER PERmrr <br /> I. FAcuiryINFoRmATioN <br /> TOTAL NUMBER Of USTS AT FACILITY FAClLrrYiD# <br /> —:2� (Agencyukoffly) <br /> BUS94ESS NAME(Smc.FACn=NAhMwDBA-D�u,�m)2e,1ZS1 37 <br /> BUSINESS SITE ADDRESS CITY <br /> le'l —11,57101ee , <br /> FAciLrrYTYPE I@ i.moToRvEHIcLEFuELING 0 2.FUEL DISTRIBUTION Is the fiacility located on Indian Reservation or 40. <br /> 0 3.FARM El 4.PROCESSOR 1:1 6.OTHER Trust lwds? E]Yea CKNO <br /> H. PROPERTY OVA'qER INFORMATION <br /> PROPERTY OWNER NAME PHONE 408. <br /> MAILING ADDRESS _7— fy <br /> ///91�y <br /> CITY 410. STATE 411. 21P CODE 411 <br /> HL TANK OPERATOR INFORMATION. <br /> TANK OPERATOR NAME 4�L 1 PHONE 42&2 <br /> MAILING ADDRESS 42&3 <br /> A/ e-7. <br /> CITY 41&4 4�1 1 ZIPCODE 428� <br /> ew <br /> STATE <br /> IV. TANK ONVNERINFORMATION <br /> TANK OWNER NAW 414. 1 MOM 4-13 <br /> 9kY—//;E:? <br /> MAILING ADDRESS 416 <br /> /Z/ <br /> CITY 417. 1 ST <br /> 41S. 1 ZIP CODE 419, <br /> OWNER TYPE: 0 4.LOCAL AGENCYIDISTIUCT 0 5.COUNTY AGENCY 0 6.STATE AGENCY 420� <br /> [3 7.FEDERAL AGENCY 9^.NON-GOVERNN[ENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEEACCOUNTNUMBER <br /> TY(TK)HQ44- 101141 -2 Call the State Board of Equalization,FwlTu Divisim iftbacm questions. 421. <br /> VL PERMIT HOLDER INFORMATION <br /> Issue Permit and send legal notifications and mailings to: Rr 1.FACILITY OWNER [14.TANK OPERATOR 423 <br /> El 3.TANK OWNER 0 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 40& <br /> VIEL APPLICANT SIGNATURE <br /> CERTMCATION: I cerlify dt"e bribirtannuffm provided herein is e�acculrate.said in fall comoliance with legal mquiresuensts. <br /> AP7� SI Ae <br /> DAT�� 424 PHONE 72-57 <br /> AVKICANT NAME(p6W <br /> APPLICANI ITIL& 4V <br /> UPCF UST-A Rev.(12MM <br />