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U <br /> f,,I UNIFIED PROGRAM CONSOLIDATED FORM <br /> ryl ID UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> �� (One Porn per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT C?5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400" <br /> (Check one arm only) ❑ 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 4N. FACILITY ID N 'r _1 A t <br /> (Agency Use Only) "� — (/ 1 — ` 0 <br /> BUSINESS NAME(save.snc¢ NAA¢«Dm-onivaehaiv®ne) ; <br /> t . _ A4 PM <br /> BUSINESS SITE ADDRESS 103. CITY 1a. <br /> � ,�j ,Alli- W . `10SEw11T[ V. MA T e c A <br /> FACILITY TYPE ELA-%.OTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' I Is the facility located on Indian Reservation or 4Q5' <br /> 3.FARM 4.PROCESSOR El 6.OTHER Trust lands? ❑Yes QMR' <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4% PHONE aos. <br /> ss cs c <br /> MAILING ADDRESS 409. <br /> 2313 3 �oC Ler �' <br /> CITY FApp r� 410. STATE 411. ZIP CODE q -3 <br /> 412. <br /> C l�S J� <br /> TANK OPERATOR NAME PS R AS 1 i tv,c- 4�t. PHONE aze-z <br /> PS 3 ) 91-(a - <br /> MAILING ADDRESS 428-3 <br /> PP,SE-0 F W TR.A D P <br /> CITY 42&4 STATE 42&S ZIP CODE 4286 <br /> T)KLJC iL I C A- <br /> IV. <br /> --IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 4M PHONE 4M <br /> - (;A FR7 �t.+AiFe- - ( ) <br /> MAILING ADDRESS sib. <br /> CITY 4n. I STATE 418. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ,❑ 5 6..CCOUNY AGENCY [16.STATE AGENCY 420. <br /> [17.FEDERAL AGENCY e— NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 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 UrlTANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406' <br /> VH.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> PLCANTSIGNATU�I F.'r� - DATE I 11 4u PHONE <u- <br /> APPL[ ANT NAME(print) 426. I APPLICANT TITLE 427 <br /> Rrv1 L AJ( � f RE)iDC N7 <br /> UPCF UST-A Rev.(12/2007) <br />