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UNIFIED PROGRAM CONSOLWPATFD FORM � <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INF RMO <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT )ED-CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Check one item only) 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404'-[FACILITY ID# <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as FACII.I7Y NAME or DBA-Doing Buwess As) 3. <br /> i /_C <br /> BUSINESS SITE ADDRESS - CITY 104. <br /> D/ f1 -403 <br /> off <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM [14.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ANo <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE <br /> MAILING ADDRESS 409. <br /> Aq oL a <br /> CITY 410STATE 411- ZIP CODE 412. <br /> c.� 9.x.33 7 <br /> III. TANK OPERATOR INFORMATION <br /> TANK ERATOR NAME N 428-1. PHONE 428-2 <br /> MAILING ADDRESS 428-3 <br /> CITY 4]8 4 STATE 42g 5 ZIP CODE 42" <br /> IV. TANK R INFORMATION <br /> TANK OWNER NAME 414. /PHONE 415. <br /> ATl <br /> MAILING ADDRESS 416. <br /> CITY 412 STATE 418. ZIP E 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.S AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORACE F _"_!'C'^U <br /> FF NT NUMBER <br /> TY(TY,)HQ Call the State Board of Equalization,Fuel Tax Division,if there are questions. AL1' <br /> q - 0 q 3bftllftqhT HOLDER INFORMATION <br /> 423 <br /> Issue permit and send legal notifications and mailings to: I.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify at the informatinn nrnvirlml hprpin is trip nprnratp and in roll Pomnlianvp with Ipaal rvnnirPmeF0. ' <br /> APPLICANT SIG*: <br /> D Tr __ ._.•__-A'iA I nr.��ir- _.-_ --n __-_ ---425. <br /> A' - A <br /> APPLICANT NAME(print) Cq0Lj <br /> 426. APPLICANT TITLE 427 <br /> � <br /> 4 <br /> UPCF UST-A Rev.(1212007) <br />