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t'�'51,?I►� <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION Lam" 14' <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) b 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF i1STs AT FACILITY 404 FACILITY ID# _ _ 1 <br /> +�•,,'J (Agency Use Only) <br /> BUSINESS NAME(Same u FACILn Y NAME?or DBA-Di n usinesss As) 3. <br /> V'4'--v <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> a � . <br /> FACILITY TYPE C�,-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 OWNS AME 407. PHONE 408. <br /> V N .a '¢te 7- <br /> MAILING ADDRESS 409. <br /> CITY 410. STATE 411. 1 ZIP CODE 412. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4211. PHONE 428-2 <br /> MAILING ADDRESS 428-3 <br /> CITY 428 a [STATE41-5 ZIP CODE 428-6 <br /> ( 963 0 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 714PHONE 415. <br /> s 00 ✓ ) <br /> MAILING ADDRESS 416. <br /> CITY a1z STATE 418. 1 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(TIC)HQ 44- 1 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: [r1.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 accurate and in full compliance with legal re uirements. <br /> APPLICA ATURE DATE 424 1 PHONE 425, <br /> s=ip-A <br /> APPLICANT NAME(print) /'� 426. APPLICANT TITLE 427 <br /> y � � <br /> UPCF UST-A Rev.(12/2007) <br />