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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK GX OPERATING PERMIT APPLICATION-FACILITY INFORMATION (One form per facility) TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400 (Check one item only) 3.RENEWAL PERMIT 6.TEMPORARY FACILITY CLOSURE ❑ ❑ 9.TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF LISTS AT FACILITY 404. FACILITY ID# _ _ t (Agency Use Only) 3191 t r BUST S NAME(Same as FACILITY NAME or DBA-DoinpiBusiness As) 3. BUSINESS qJTE ADDRESS 103. CITY 104. 16 16 ) )4Al FACILITY TYPE 1 I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on In tan Reservation or 405. ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes No II. PROPERTY OWNER INFORMATION PRO ERTY OWNER NAME 407. 1 PHONE 408. (Ile% � MAILING DRESS 409. CITY alo. STA an. ZIP CO E, 412. F III. TANK OPERATOR INFORMATION TANP OPERATOR NAME 428-1. PHONE 2 428-2 MAILING ADDS 428-3 Z 3 �'. CITY/ n 428-0 STATE 428-5 ZIP ODE 428-6 /�U IV. TANK OWNER INFORMATION TANK OWNER N E Ota. PHONE 415. MAILING DDRESS ale. CITY 417, ST TE ata. ZIP C DE 419. V` 'W�1. OWNER TYP /I 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 101-2- 14- 1Q, I AS 10 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. VI.PERMIT HOLDER INFORMATION Issue permit and send legal notifications and mailings to: 1.FACILITY OWNER 423 pe g g ❑ 4.TANK OPERATOR ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. VII.APPLICANT SIGNATURE CER FICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements.- mg NA RE DATF 424. PHONE z 2 f AP ANT AME rint 426. APPLI A TLE J�J !/r27 UPCF UST-A Rev.(12/2007)