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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK OJ <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION �QN <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400' <br /> (Check one ttem only) ❑ 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY FACILITY ID# _ _ <br /> 3 (Agency Use Only) <br /> BUSINESSNAME(Samem F. 'ity Name or DBA-Doing Business As) s.' <br /> DKs I hv. C I <br /> BUSINESS SI¢EADD ESS�C n 103. CITY` v CAGZr» 104. <br /> FACILITY TYPE ET I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ L Yes ❑ 2.No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407, PHONE 408. <br /> D \ S NV . <br /> MAILING ADDRESS 409. <br /> CITY L FyPm� 4io. STATE Ott ZIP CODE 41x <br /> -kQ�i/ C tl U S 3 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 1 428-1. PHONE 428.2. <br /> KGVGw 1 � I 09 ) E-( 'A &S-$) <br /> MAILING ADDRESS 428x. <br /> `-1 L <br /> CITY 4284 STATE 428-5. ZIP CODE 4284, <br /> S �y4 C '� 9 C7 • <br /> IV. TANK OWNER INFORMATION <br /> ��i, <br /> TAN OWNER NAME ata. PHONE re ns. <br /> MAILING ADDRESS C OY C.I./ 416. <br /> CITY Qv r, STATE 418. ZIPCODE 419. <br /> V C C(�A I . <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER 1 <br /> TY(TK)HQ 44- 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 1.FACILITY OWNER 0 4.TANK OPERATOR 423. <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Requiredjor Public Agencies Only) 406. <br /> VII. APPLICANT SIGNATURE „ <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLI NATURE DATE 424. PHONE 425. <br /> V oS INA <br /> � 5 a �s� u Fs�B1 <br /> APPL C NAME(print) 426, APPLICANTTITLE 429 <br /> G Vq w. S >n U . Ml or <br /> UPCFUST-A Rev.(12/2007)-1/2n L/ www.unidocsxrg <br />