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4 <br /> UW" CONSOLIDATED FORM <br /> UNDERGROUND S•IIORAGE TANK INFORMATION O <br /> OPERATING PERMIT AppLICATION-FACILITY <br /> (One foram pc facility) m <br /> 5.CHANGE OF IIiFtORMATION ❑ m7 PERMANENT FACILITY CLOSURE <br /> TYPE OF ACTION la 1.NEW PERMIT ❑ Y FF OLTPY CLOSURE ❑ 9.TRANSFER PERMIT <br /> (Chi ons itm•only/ ❑ 3.RENEWAL PERART ❑ G TF.MPORAR <br /> I. FACIIdTY INFORMATION F/2j V 7-7.2T <br /> TOTAL NTIAIBER OF LSTs.AT FACKn 1 uu F:\CR.11 I ID <br /> BUSINESS NAD�ISmne us Fao� \�/rDH Business, sI��N <br /> 1M <br /> IOi (Tfl� <br /> BUSINESS 9.1,DC S <br /> xn Is 1Le facility located m Indira Reservation <br /> or <br /> FACILITY TYPE la 1.MOTOR VFIRCI.E pTJE[,RJO ❑ 2 FUEL DISTRIBUTION Is <br /> lands^ ❑ I"1"es 1!3a No <br /> 3.FARM 4.gTOCESSOR Q &OTHER <br /> II. PROPERTY OWNER INFORMATION <br /> n PHONE <br /> PROPERTYo NER N-VIE QN�• (�l� `3��— O� <br /> 4�M`A— <br /> b\L V <br /> rLAILING.ADDRESS <br /> QlbG 13 S o <br /> ,ia STATE „t Zip CODE <br /> Cm UA <br /> b 1 <br /> III. TANK OPERATOR INFORMATION <br /> PHONE <br /> TANK OPFRAroR NAME n N L <br /> I&AH.ING"ADDRRESS <br /> U3�� CODE <br /> (TTY 3`1 <br /> E b � <br /> IV. TANK OWNER INFORMATION 41, <br /> ,u PHONE <br /> TANL:O\1NERNAhfE L \ <br /> ,L(u �' -{ ,tF <br /> rLAR.ING ADDRESSVc��} <br /> \3`7 <br /> ata ZIP CODE 419 <br /> CITY at SLATE , A cj4 J <br /> 6.STATE AGENCY a-o <br /> p°"I�TY�" ❑ <br /> 4.LOCAL AGENCYMISTRIC'f ❑ 5.COUNTY AGENCY ❑ <br /> 8 NONGOVFRNMENT <br /> 1:17.FEDERAL.AGENCY �. <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER ,t <br /> Stale Bond of Egval®tiov.Pd Tax Division,if III=are questiore" <br /> TY(TK)HO4't- ©. <br /> VI.PERMIT HOLDER INFORMATION <br /> 1.FACB/TY OWNER 4.TANK OPERATOR <br /> Iawe peewit and send Wod w ifieatiom and ,,ilaw b: ❑ 5.FACILITY OPERATOR <br /> E] 3.TANK OWNER uw <br /> SUPER\TSOR OF DI\7SION.SECTION.lNt OFFICE IR'.4+cared{car Pnbhc.i.4enci rs Onh'1 <br /> VII APPLICANT SIGNATURE <br /> sided lsesm is eve,acrnrak,amd'm fuR com liantr svitls k sdrmlmts. <br /> q ,±a PHONE <br /> i• CATION: I rer/Hs.drat amation DATE <br /> SIG <br /> .' <br /> ,.n ..1ppTll'.ANT TLE <br /> ANT N.Ats (Pf W) i \ L <br /> srsm.vvidoa.arg <br /> UPCF UST-A Rev.(1712la7)-I!J', <br /> cn � � <br />