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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION j <br /> (One form per facility) � <br /> TYPE OF ACTION ❑ 1.NEW PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE / <br /> (Chale one item only) ❑ 3.RENEWAL PERMIT 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> 1. <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACLITY ID# <br /> (Agency Use Only) <br /> BUSINESS NAME(Smaa FAcftJrY NAebEUDm-M ammm A4) <br /> M �J7F� �Z o LCC . <br /> IN. <br /> BUSINESS SITE ADDRESS 103. Cil1 <br /> i� IS- w osC-- Al <br /> 05. <br /> FACILITY TYPE L MOTOR VEHICLE FUELING [12.FUEL DISTRIBUTION 401 Is the facility located on In ' Reservation or <br /> 3.FARM 4.PROCESSOR 6.OTHER Trust Inds? ❑Yes No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 402. PHONE °m' <br /> Crts StEcs (N(- <br /> �L3 <br /> MAILING ADDRESS V L O �� <br /> e� 410. STATE 41�. ZIP CODE p� alz <br /> CITY / J _7 <br /> IH. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME n 42&1 PHONE 428-2 <br /> Nf�i �FC-A �F7FO u C 01� <br /> 42 1 <br /> MAILING ADDRESS ti <br /> Y c-AsT>,r�- fi«c C T _ <br /> CITY 4244 STATE ass IIP CODE °}� <br /> SI F U/1, C-149, 7P <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERN , 414. PHONE 415. <br /> 416 <br /> MAILING ADDRESS <br /> <- h <br /> CITY sn. STATE sls. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4m. <br /> ❑ 7.FEDERAL AGENCY 10 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 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 notification and tmilinp to: ❑ 1.FACILITY OWNER 4.TANK OPERATOR <br /> 415 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> sob. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Ageocies Only) <br /> VH.APPLICANT SIGNATURE <br /> CERTIFICATION: ftErtify that the information provided herein is tree accurate and in full con Bance with legal requircumenlL <br /> APPLICANT SIGNA `_ �(I DATE r. �7 / L , 4za. PHONE n -� <br /> APPLICANT (prvn) 426. APPLICANTl1YT1TLE Uf1 9n <br /> L l � \7 <br /> UPCF UST-A Rev.(12/2007) <br />