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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION El 1.NEW PERMIT El 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) [13.RENEWAL PERMIT <br /> El 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 41. FACILITY ID# _ 1. <br /> (Agency Use Only) <br /> BUSINESS NAME(Sonem FACRITYNAb orDBA-Wing Bmif As) 5 <br /> BUSINESS SITE ADDRESS 105. CITY l04 <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> 3.FARM 4.PROCESSOR 6.OTHER Trust lands? ❑Yes ❑No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME PHONE 4oe. <br /> MAILING ADDRESS 4a9 <br /> CITY 410. STATE 411. ZIPCODE 412. <br /> HI. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE ` 428-2 <br /> MAILING ADDRESS / 4285 <br /> CITY 4'-a-0 STATE 42s-5 <br /> ZIP CODE 4284 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. 1 <br /> /PHONE 415. <br /> MAILING ADDRESS ` <br /> 416. <br /> CITY 417. 1 STATE 418. ZIPCODE 419. <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- 1 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 425 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICER(Required For Public °06 <br /> ( equ' Agencies Only) <br /> VH.APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certify that the information provided herein is true accurate,and in full com Bance with le al requirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 425. <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> UPCF UST-A Rev.(1212007) <br />