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03/0312011 20: 0° 5107953470 SH-00-44rop <br /> CSE 02 <br /> At"' <br /> UNIFIED fROGR.AM CONSOLIDATED FORM 310 It <br /> UNDERGROUND S'T'ORAGE TANX <br /> OPERATING PERMIT APPLICATION —FACILITY INFORMATION <br /> (One form Pfr facility) <br /> TYPE OF ACTION ❑ J.'NEW PERMIT 0 5.CHANGE OF INFOP,,N AT10N ❑ 7.PETttia kNNF 3T FACILITY CLOSURE <br /> (Check orx item only) 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PEPMIT <br /> I. FACILITY INFORMATION <br /> TOT.AL NUMBER Of LISTS AT FACILITYuu. FACILITY ID ti � 1 <br /> 3 (4gencv Use On4:) F A I L (++ Q <br /> BUSINESS NAME(Same as Facility Name or,9L1,4—Doing 31atmess.I8) <br /> r M A'i tA �g B E Y PcfZLD ISM P M_-- J S V—S F—MTEGLP�,1 i E !N C. <br /> 13USUFESS SITE'ADDRESS 103. CITY- I104. <br /> FACILITY'TYPEI.MOTOR VEHICLE FUELING C12.FUEL DI51-1;I8UTION 40' Is the f'LCihty located ou Indi Reservation or <br /> sus. <br /> [( 3.FARM 4.PROCESSOR C36.OTHFR Trusi lands' ❑ 1.Yes 2_No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTOWNER NAME 407. PRONE' "d° <br /> Y <br /> JF-SKUL ENZERPPlSE LLC_ ja��� <br /> NLULING ADDRESS w °� <br /> G � ��S L ktl� <br /> CITY 410. STATE 411. ZIP CODE 412' <br /> cZFrAoWF R�5 3 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME -- 423-1. 1 PFIONE 4=8= <br /> `(`AAA S-MEET Ik+LCZ JSeS ENTW4se<, ! (2-09 ) SES- (o c4- <br /> MAILING ADDRESS 423-3. <br /> Do <br /> CFCY i"8� CODE 42n,6. <br /> N1 NW TIP, SF <br /> � S 3� �- <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME �,4: I PH0NF 415. <br /> A114 S'T4 LEALC-0 W061 — JSLs EVTQ0A1sESI(.�r f �R )��5 <br /> ^ 416. <br /> MAILING ADDRESS <br /> d �, {111 N ST El?Z <br /> CITY 417. STATF Sia. VP CODE 4t9 <br /> OWNER TYPE: ❑ 4-LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGFNCY azo. <br /> ❑ 7.FEDERAL AGENCY 8,NI ON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> r TY(TK)HQ 44_ (? ( 5 J I Call the State Roard of Equalization.Fuel Tax Division,if there are questions. 421. <br /> VL PERMIT HOLDER.INFORMATION <br /> Issue permit and send legal aotifications mtd mailings to: ❑ I.F.AC(LFTY 0WNF9 ❑ 4-TANK OPERATOR <br /> ❑ 3.TANK OWNER 5.FACIT FFY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION.OR OFFICE(Requiredf)r Public Agencies Only) 406 <br /> V FL APPLICANT SIGNATURE <br /> CERTIFICATION: I Certify that the information provided herein is true accurate,and in f th legal re uirentents. <br /> APPLICANT SIGNATURE ^ DATE PITO T res. <br /> (2©l 00'L'3 <br /> APPLICANT NAME(Print) 425. APPLICANT-FULF 427 <br /> KOLDEEP C C VkkVV\A-- C-Et _ <br /> UPCF LIST-A Rev,(:IV207)-1/2 wwwmaidoe3-org <br />