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Vy(I?1►-1 <br />UNIFIED PROGRAM CONSOLIDATED FORM AD0>4o*-D - <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT APPLICATION - FACILITY INFORMATION L l <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 I AT FACILITY 404. <br />FACILITY ID # <br />(Agency Use Only) <br />BUSINESS NAME (Same as FACILITY NATE or DBA - in usine/ss As) 3_ <br />V <br />BUSINESS SITE ADDRESS 103. <br />CITY 104. <br />a Aj . m /0s; <br />e <br />FACILITY TYPE C�,_1. MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 403 <br />Is the facility located on Indian Reservation or 405. <br />❑ 3. FARM ❑ 4. PROCESSOR ❑ 6. OTHER <br />Trust lands? ❑ Yes ❑ No <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNE AME 407. <br />PHONE 408. <br />/� <br />�6 <br />t9 <br />�J - <br />MAILING ADDRESS 409. <br />/ A <br />CITY 410. <br />STATE 411. <br />ZIP CODE 412. <br />III. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 428.1. <br />428-2 <br />9- UP,'-/ I Ili <br />/PHONE <br />- <br />MAILING ADDRESS 428-3 <br />CITY 428-4 <br />STATE 428-5 <br />ZIP CODE 428-6 <br />C.4 <br />Q5 3 0 <br />IV. TANK OWNER INFORMATION <br />TANK OWNER NAME 414. <br />PHONE 415. <br />s� Bin 1; <br />MAILING ADDRESS 416, <br />CITY 417. <br />rTATE 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- 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: Erl. FACILITY OWNER El4. 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 com fiance with le al re uirements. <br />APPLICA ATURE <br />DATE 424. <br />s/ <br />PHONE 425. <br />3 <br />APPLICANT NAME (print) 426, <br />mw�t�Iti <br />APPLICANT TITLE 427 <br />el <br />!L <br />UPCF UST -A Rev. (12/2007) <br />