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Aft <br /> IFIED PROGRAM CONSOLIDATED FO Ll� <br /> �* JrUNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> 19 w (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ® 7.PERMANENT FACILITY CLOSIJE <br /> o <br /> (Check one item only) ❑ 3.RENEWAL PERMIT E] 6.TEMPORARY FACILITY CLOSURE [:19.TRANSFER PERMIT 1 1 <br /> ov <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# _ _ 1 <br /> 1 (Agency Use Only) � <br /> d � AJ 1 ��7 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) <br /> Levand Bright Family Trust Propertyf�`�N 1` '•}I STC <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 3 East Eleventh Street Trac <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 NAME 407 PHONE 408. <br /> Louis Levand Trust,Et.al. (661) 904-2133 <br /> MAILING ADDRESS 409. <br /> 24692 Sand Wedge Lane <br /> CITY 410. STATE 411. ZIP CODE 412, <br /> Valencia CA 91355 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 PHONE 428-2 <br /> Unknown ( ) <br /> MAILING ADDRESS 428-3 <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Louis Levand Trust,Et.al. (661) 904-2133 <br /> MAILING ADDRESS 416, <br /> 24692 Sand Wedge Lane <br /> CITY 41T STATE 418. ZIP CODE 419, <br /> Valencia CA 91355 <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: ❑ 1.FACILITY OWNER El4.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 /> APPLICANT S1TUI DATE 424, PHONE 425. <br /> UJ02/03/2014 (209) 467-1006 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> William Little Agent for Levand Family Trust <br /> UPCF UST-A Rev.(12/2007) <br />