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UNIFIED PROGRAM CONSOLIDATED FORM Qr S Z Gdv <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT t6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L 0 2 / �t 5 I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' 1 FACILITY ID# _ _ r <br /> (Agency Use Only) J r O <br /> BUSINESS-NAME same as AAaLnY NAWor DBA-Doing Business As) 3. <br /> r C:4- <br /> BUSINESS SITE RES 103. CITY 104. <br /> r CS , <br /> FACILITY TYPE `[�1.MOTOR VEHICLE FUELING 403. <br /> +y J� ❑ 2.FUEL DISTRIBUTION Is a facility located on ndi Reservation or <br /> 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes No <br /> H. PROPERTY OWNER INFORMATION <br /> PR WNER NAME 407. PHONE 408. <br /> -) :' I J, , -2 <br /> A CA <br /> MAIL DDRESS 409. <br /> CITY 410. 1 STATE 411. 1 ZIP CODE(' 412. <br /> J <br /> 111. ANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 42-8-1 PHONE 428-2 <br /> MAILING ADDRESS 428-3 <br /> CITY 428-4 1 STATE 428-5 ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Gc�k "\.D- % <br /> MAILING ADDRESS 416 <br /> CITY 417. 1 STATE 418. 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 pen-nit and send legal notifications and mailings to: 1.FACILITY OWNER 423 <br /> pe g g ❑ 4.TANK OPERATOR <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 /> CERT (CATION:11 certify that the information grovided hereioAQis true,accurate,and in full compliance with legal requirements. <br /> APPLI NT GNATURE DATE , 424. PHO E ) _�� 2s <br /> APPLICANT N 426 APPLI NT'rITLE 4n <br /> c� <br /> UPCF I'S"r-A Rev.(12/2007) ` <br />