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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400' <br /> (Check one item only) ❑ 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L FACILITY INFORMATION OD D f 1 q <br /> TOTAL NUMBER OF USTs AT FACILITY 4N. FACILITY ID* _ 1. <br /> (Agency Use Only) <br /> BUS ESSN (s.m .FACH=NA orDBA-DangBminevsAs) 'i 3 <br /> eA_6131iptaw, `'3 VG cJ✓� Gin (� V� <br /> BUSINFSS SITE ADDRESS 103. Clpy loo <br /> 1,A20 vj. <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 El 6.OTHER - Trust lands? ❑Yes n blo <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERA OWNER NAME 402, 1 PHONE 408. <br /> VAI•\ 510 <br /> MAILING ADDRESS 409 <br /> 1 vt= <br /> CITY 410. <br /> STATE au. ZIP CGDE 412. <br /> --bec 0, el A �S337 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPE RAT N _. 428-1. PHONE 4213-z <br /> 61 , a iv ( Slo ) `73Lt - 1g11I <br /> MAILING ADDRESS <br /> y� 428-3 <br /> 6S'2wi-ie V <br /> CITY 42134 STATE aze-s <br /> ZIP CODE azes <br /> Ma a e- <br /> C}533Z <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME <br /> ma. PHONE 415. <br /> it 'y Si ( S(v <br /> MAILING ADDRESS�Ak 416 <br /> 1 V <br /> CITY 417. STATE 418, 1 ZIP CODE 419. <br /> Ma^� 139. <br /> C-_A, �S 23 7- <br /> OWNER TYPE: _ ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY <br /> El 7.FEDERAL AGENCY El 6.STATE AGENCY 420: <br /> ❑ S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNTNUMBER <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 /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5..FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OROFFICE For Public Agencies Only) . 4013. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certi that the information rovided herein is tru accurate and in full com Bance with It al re uirements. <br /> LICANTSIGNAnmu DATE 424. PHONE 4zs. <br /> S o L1 tr6 k <br /> AP ICANT (Drint C `N L az6.11/ APPLICANT TITLE 1`lIJ J an <br /> UPCF UST-A Rev.(12/2007) <br />