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i <br /> IIh, <br /> V44t <br /> UNIFIED PROGRAM CONSOLIDATED FORM ' <br /> UNDERGROUND STORAGE TANK s1b <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION `J <br /> (One limn per facilites) <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 USTs AT FACILITY 404. FACILITY ID# --[-]-T <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as FACIIATY NAME or DBA-Doing Business As) 3. <br /> r+ f a o hi 0,,v e-0 h <br /> BUSINESS SITE <br /> ADDRESS103. <br /> /� 103. CITY 104. <br /> t7 L1 12 1 C 7 1 Q }0 1 AYe- �' <br /> FACILITY TYPE 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 OWNER NAME407 PHONE 408• <br /> IJA <br /> ING]�ADD SS �j 409. <br /> -V - , - ---Iq II__ ' CA ✓ 412. <br /> CITY 410. STATE 4u. ZIP CODE <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> k�kl <br /> MAILING ADDRESS <br /> CITY 4284 STATE 428-5 ZIP CODE 42s-6 <br /> 1-b t-1i e. A4 I Ot 5' 2-L42- <br /> IV. <br /> 42- <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415, <br /> 1j A L-G h to M I R\ b`t -7 S <br /> MAILING ADDRESS 416. <br /> ti 21 e <br /> CITY e 417 STATEata. ZIP CODE Z 419. <br /> L_otLi' Ig <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4'0 <br /> ❑ 7.FEDERAL AGENCY 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY('IK)HQ 44- 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: I.FACILITY OWNER [14.TANK OPERATOR 423 <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 that the information provided herein is true,accurate and in full compliance with legal requirements. <br /> P IC S NATURE DATE 424. PHONE 4' <br /> f4W v4 k �� 33 -1 6712- <br /> APPLICANT N (print) 426- APPLICANT TIT 4 <br /> ►U 'FYI 01 <br /> UPCF UST-A Rev.(12/2007) <br />