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UNIFIED PROGRAM CONSOLIDATED FORIVTt <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION I.NEW PERMIT ❑ 5,CHANGE OF INFORMATIONa00 <br /> (Check one item only) ❑ 7.PERMANENT FACILITY CLOSURE <br /> ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY °04 FACILITY ID H _ <br /> (Agency Use Only) <br /> 3 � 7 <br /> BUSINESS NAME(Sameaciiitv Name or DBA-Doing Business As) X�T 0. <br /> BUSINESS SITE ADDRESS _I v /✓� 100. CITY 104- <br /> B24 Ff `,'bwNl liz JOUE (VIA'KTt7" , (�!A - MI533& <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403, Is the facility located on Indi�y'Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ I.Yes 612.No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407, PHONE 4oa <br /> i E�TRC) tf- M VF--_J URCS , LLC' (2oc) 57"7- 60o0 <br /> MAILING ADDRESS 409. <br /> Pool fVIC� �y /AVE <br /> CITY 4M 1 STATE 411- ZIP CODE 412. <br /> (VL t)DE eA iso <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428.2_ <br /> ` Kko1 , usO ) 71 - 97- 4 <br /> MAILING ADDRESS 1 V � <br /> 428-3. <br /> CITY 4284STATE 428-542fi. <br /> A , / / J <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414, PHONE 415. <br /> P�`f72DI.fi'lAM V TM2 ISG ( °I) 5`Z7-b00 <br /> MAILING ADDRESS 416. <br /> b t Mn W/V9� f6,�1"l ff <br /> CITY �1�/�l� 417. 1 STAT A' 418. ZIP COD'q�)W 419. <br /> OWNER TYPE: [14.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑'(6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY [9/8.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 /> 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,OR OFFICE(Requiredfor Public Agencies Only) 406. <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full com liance with legal requirements. <br /> APPLICANT SI RE DATE 420 PHONE 425, <br /> APPLICANT NAME(print) 426. APPLI AN TITLE' - 420 <br /> UPCF UST-A Rev.(12/2007)-1/2 4v4vw.unidocs.org M ' 1J 1 <br /> KV, <br />