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�61,111-1 <br />UPCF UST -A Rev. (12/2007) <br />UNIFIED PROGRAM CONSOLIDATED FORMD <br />UNDERGROUND STORAGE TANK <br />E: <br />OPERATING PERMIT APPLICATION - FACILITY INFORMATION Li6A- If - <br />(One form per facility) <br />TYPE OF ACTION 1. NEW PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 7. PERMANENT FACILITY CLOSURE 400. <br />(Check one item only) 3 RENEWAL PERMIT ❑ 6. TEMPORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT <br />I. FACILITY INFORMATION <br />TOTAL NUMBER OF �JSTs AT FACILITY 404' <br />FACILITY ID # <br />_ <br />_ <br />1. <br />�„+j <br />(Agency Use Only) <br />BUSINESS NAME (Same as FACILITY NAME or DBA Doi urine/ss/�As) 3 <br />In A�AJ Ziof t-4�/ / 1�i1-'O -i/ <br />BUSINESS SITE ADDRESS 103. <br />a s; <br />CITY 1oa <br />k) , � <br />��7p- <br />FACILITY TYPE 1. MOTOR VEHICLE FUELING 403. <br />❑ 2. FUEL DISTRIBUTION <br />405. <br />Is the facility located on Indian Reservation or <br />❑ 3. FARM ❑ 4. PROCESSOR ❑ 6. OTHER <br />Trust lands? ❑ Yes ❑ No <br />U. PROPERTY OWNER INFORMATION <br />PROPERTY OWNE NAME 407. <br />PHONE aoa. <br />N <br />S <br />MAILING ADDRESS 409. <br />CITY 410. <br />STATE 411. <br />ZIP CODE 812. <br />III. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 428-1. PHONE 428-2 <br />2- <br />0, P'A - AJ z. 4$7-Z <br />MAILINGADDRESS 428-3 <br />CITY 4284 <br />STATE 4z8-5 <br />ZIP CODE 428-6 <br />/ n ^ <br />C� <br />Q5 3 0 <br />IV. TANK OWNER INFORMATION <br />TANK OWNER NAME 414. <br />PHONE 415. <br />-sem s� v <br />c <br />MAILING ADDRESS 416 <br />CITY 417. <br />STATE 418. <br />ZIP CODE 419. <br />OWNER TYPE: ❑ 4. LOCAL AGENCY/DISTRICT ❑ 5. 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- Call the State Board of Equalization, Fuel Tax Division, if there are questions. 821' <br />VI. PERMIT HOLDER INFORMATION <br />Issue permit and send legal notifications and mailings to: Erl. FACILITY OWNER ❑ 4. TANK OPERATOR 423 <br />❑ 3. TANK OWNER ❑ 5. FACILITY OPERATOR <br />SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies Only) 406. <br />VII. APPLICANT SIGNATURE <br />CER ICATION: I certify that the information provided herein is true <br />accurate and in full compliance with legal re uirements. <br />APPLICA ATURE <br />DATE 424. PHONE 421. <br />.Ss// � <br />-153 <br />APPLICANT NAME (print) 426• <br />APPLICANT TITLE 427 <br />UPCF UST -A Rev. (12/2007) <br />