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UNIFIED PROGRAM CONSOLIDATED FORM q UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form <br /> TYPE OF ACTION ❑ 1.NEW W PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Ch«tone tram only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY .4 40°' FACR.ITY ID# <br /> J (Agency Use Only) 3 <br /> BUSINESS NAME(g ss FACam NAhm or DBA-Doing nmm) 3. <br /> U -So 6 <br /> BUSINESS SITE ADD SS 103. CITY IN <br /> Jvzlo ti ;'T. S oe"KToN <br /> FACILITY TYPE ;9 L MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 903' Is the facility located on Indian Reservation or 47. <br /> rl 3.FARM 4.PROCESSOR El 6.OTHER Trust Inds? ❑Yes No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 401, PHONE 408. <br /> 6s0 7 -7991. <br /> MAILING ADDRESS 409. <br /> CITY �I / 4t0. STATE 411. ZIP CODE 412. <br /> Iles <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> ,Te .v ee� (". O U74- 99 Z <br /> MAIILLIN�G`ADDRESS p o 428-3 <br /> l <br /> O J •GQ rJ {,/� `�, <br /> CITY 4284 1 STATE 428-5 1 ZIP CODE 42M <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Ue � ee (6,50LZ7 - 799� <br /> MAILING ADDRESS 416. <br /> CI'{'Y 41z STATE 41s. Zd�O� 415. <br /> e5 o 9 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 40. <br /> ❑ 7.FEDERAL AGENCY C9 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TIC)HQ 44- 1 1 Call the State Board ofEqualiration,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 4 J <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 /> AP CAM SIGNATU D4TE 424. PHONE <br /> 6 2 e 0 7/- <br /> APPLICANT NAME cce�nt) 436 APPLICANT TITLE <br /> pe-11-1<-6 <br /> UPCF UST-A Rev.(12/2007) <br />