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UN UNDERGROUNDSTORAGE TANKORM D C O 1 <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (nae ram pu aeanr) <br /> TYPE OF ACTION ❑ I.NEW W PERMIT 5.CHANGE OF INFORMATION <br /> (C6erY one item only) ❑ 7.PERMANENT FACILITY CLOSURE 'a"'' <br /> ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTI AT FACILITY 401. <br /> FACILITY ID q I. <br /> BUSINESS NAME (ASrncy Use Only.) — — <br /> (Suro n rAC¢.rIV NAME wDBA-D^W Bisinm.As) <br /> 3. <br /> BU NESS SITE ADDRESS <br /> CITY <br /> FACILITY TYPE 91 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION mss' <br /> Is the facility lasted on Indian Reservation or Im' <br /> 3.FARM 4.PROCESSOR 6.OTHER Trust lauds? ❑Yes ®No <br /> U. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME <br /> PHONE 401. <br /> M LING SS 20(9 <br /> 16888 McKinle Ave <br /> CITY <br /> 41s. STATE 111. ZIP CODE <br /> Ili <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 429-1. PHONE <br /> 4ze-z <br /> MAILING ADDRES 209 ) 858-3384 <br /> 1Ave <br /> crry <br /> 4� STATE 4�5 ZIP CODE 4294 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME <br /> au. PHONE ns. <br /> M LING ADDRESS ) 8-8-1-484 <br /> 416. <br /> Cri'1' en. STATE 419, ZIP CODE <br /> 119. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ S.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7,FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- r 6 CIA Call the Slate Board of Equalization,Fuel Tax Division,if there are questioax 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue penia and send legal notifications and mailings to: ❑ 1.FACILITY OWNER IM 4.TANK OPERATOR 4M <br /> ❑ 3.TANK OWNER ❑ S.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the Information provided herein is true accurateI and In full tom liance with 1 al r ulrements. <br /> APPLIC SIGCj.ATURE - "_ TAPPLICANT <br /> TE Iz4. PHONE 4u. <br /> L 209 858-3384 <br /> APPLICANT NAME(print) TITLE 4n <br /> Kevin er Facilit <br /> UPCF UST-A Rev.(17!2007) " <br />