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01 <br /> ,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 ❑ 6.TEMPORARYFACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITii Y _ /n <br /> (Agency Use Only) I I Y <br /> 3. <br /> BUSINESS NAME(s aFACHMM AVEN oroeA-ooiog ami Ae) <br /> SOO's � Gi UDIL <br /> BUSINESS SITEADDRES33 <br /> S cos. CITY 104 <br /> �a o W yo rrmr�� t /Y1A/Y 7EC� � 3� <br /> FACILITY TYPE JA1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indira Reservation or 40. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes K No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME402 PHONE <br /> I 408. <br /> yAiv Cl r ;N c <br /> 409. <br /> MAILING ADDRESS <br /> 4aa W. 101CMl9G flvr" MANy6e9 efJ 95�3� <br /> CITY 410. STATE 411. ZIP CODE a¢. <br /> fn tq/V ICcy C14 19 s3�� <br /> in. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> MAILING ADDRESS 428-3 <br /> CITY 4281STATE 428.5 ZIP CODE 42M <br /> B=iz c�re�fv� <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. 1 PHONE 415. <br /> S"91�a� f)S �17�'✓t ( ) <br /> 416. <br /> MAILING ADDRESS <br /> CITY 417. STATE 418. ZIPCODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4za <br /> ❑ 7.FEDERAL AGENCY ❑ S.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 /> 423 <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER S�'te4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE . <br /> CERTIFICATION: I cerci the the information provided herein is true,accurate and in full compliance with legal r ii(rements. <br /> APPLICANT SIGNATUREDATE 424. PHONE ar- 4Z. <br /> �o aq ao� o <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 4P <br /> SATi F 9iN6)4 NLAWRi V (CE PRESiff-INE €. <br /> UPCF UST-A Rev.(1217009) .. <br />