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UNIFIED PROGRAM CONSOLIDATED FORM - t <br />©�jy <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT APPLICATION - FACILITY INFORMATION L} <br />(One Corm per facility) <br />aoo. <br />TYPE OF ACTION ❑ 1. NEW PERMIT 5. CHANGE OF INFORMATION ❑ 7. PERMANENT FACILITY CLOSURE <br />(Check Dee ire. Daly) ❑ 3. RENEWAL PERMIT ❑ 6. TEMPORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT <br />I. FACILITY INFORMATION <br />TOTAL NUMBER OF USTs AT FACR.ITY 404 . <br />TY <br />FACII.I131- <br />1 (Agency Use Only) <br />BUSINESS NAME(same.. FACM. NAME-DBA-DON,,B®N A4) <br />toy. CITY 101' <br />BUSINESS SITE ADDRES <br />< t !� <br />405. <br />FACILITY TYPE 'g -I. MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION Aos' Is the facility located on Indian Reservation or <br />Trust lands? [I Yes o <br />3. FARM 4. PROCESSOR E]6. OTHER <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME PHONE <br />409. <br />MAILMG ADDRESS <br />P, o. 30 <br />Gey 416 STATE all ZIP CODE 412 <br />Jam' EJCC OL <br />III. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 428-1. PHONE 428-2 <br />42ae <br />MAILING ADDRESS <br />CITY 426A <br />STATE 428-5 <br />ZIP CODE 4zea <br />SA o <br />C <br />` - C) <br />IV. TANK OWNER INFORMATION <br />TANK OWNER NAME 414, <br />PHONE 415. <br />6 <br />(ao9)q L4 1- <br />MAILING ADDRESS 416' <br />CITY <br />jj 411 <br />STAT,Er� 418, <br />ZIPCODE 4M <br />9 ' a I -�) — <br />ST - <br />` <br />C) �? <br />OWNER TYPE: ❑ 4. LOCAL AGENCY/DISTRICT ❑ 5. COUNTY AGENCY ❑ 6. STATE AGENCY 4zo. <br />❑ 7. FEDERAL AGENCY ❑ 8. NON-GOVERNMENT <br />V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TKQ 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 />aob. <br />SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies Only) <br />VII. APPLICANT SIGNATURE <br />CERTIFICATION: I certify that the information provided herein is [rue accurate, and in full compliance with legal requirements. <br />APPSI� <br />DATE 424 <br />PHONE 4ss . <br />e <br />zG i O <br />Z S <br />APPLICANTNAME (Print) 426 <br />APPLIC TITLE 4n <br />� <br />r� <br />` <br />4 _, ) <br />UPCF UST -A Rev. (12/2007) <br />`` <br />