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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ L NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (C'heck one item wly) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBEROF USTs AT FACILITY 404. FACILITY ID# _ _ 1. <br /> 3 (Agency Use Only) 5 5 <br /> BUSINESS NAME(Same m Fa iloy Name or DBA-Doing Business As) 3_ <br /> DI<s lv,v• � vlc . <br /> BUSINESS SITE ADDRESS' L 103. CITY <br /> $4 Wo--j Ln S\ oc Iovt <br /> FACILITY TYPE 1.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? ❑ I.Yes ❑ 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 400- PHONE 408, <br /> D \ S kv\v. � <br /> MAILING ADDRESS 409' <br /> CITY W <br /> I_ V 410. STATE °11 ZIP CODIE,I 412_ <br /> C "1 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1, PHONE 428-2. <br /> <c� vaw, 1 SI ( Q09 ) E-I `4 $'�-Fsl <br /> MAILING ADDRESS 4284 <br /> 9N $ y Wes L�, <br /> CITY , �Ij-t, 4284_ STATE 428-5. ZIP CODE 428-6, <br /> SIV C9 �J � . <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414, PHONE 415. <br /> 0 \<S viv vi <br /> MAILING ADDRESS 1 416. <br /> <is e-c;l-\ C , ov �f <br /> CITY = � STATE 418. ZIP CODS A �O . 419 <br /> OWNER TYPE: F14.LOCAL AGENCY/DISTRICT 05.COUNTY AGENCY '❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY 9f 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY (TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421 <br /> VI. PERMIT HOLDER INFORMATION <br /> 23. <br /> Issue permit and send legal notifications and mailings to: 1.FACILITY OWNER El4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Reguiredfor Public Agencies Only) 4 <br /> VII. APPLICANT SIGNATURE 1 "a <br /> CERTIFICATION: I certify that the information provided-herein is true, <br /> accurate,and in full compliance with legalal requirements. <br /> APPLIIV DATE 4 , PHONE <br /> OS 1`A <br /> \ 5 * $1 u K <br /> APPL C T NAME(print) 426. APPLICAN TITLE 4n <br /> izGVgw. U { o� <br /> UPCF UST-A Rev.(12/2007)-1/2 u .unidocs.org <br />