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c <br /> 001194 OD 5l�j�p <br /> 5 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILIT'Y INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1 NEW PERMIT ❑ 5.CHANGE OF INFORMATION 400. <br /> (Check one Item only) 3 RENEWAL PERMIT ❑ 7.PERMANENT FACILITY CLOSURE <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FAC.ILWY INFORMATION <br /> TOTAL NUMBER OF UST g�T FACILITY 4R. FACILITY ID, <br /> (Agency Use Only) <br /> BUSINESS AME(Same as Facw Name or DBA-Doing Business As) 3 <br /> � l � Lw all3 , ham <br /> BU�nv�ss4>T��ss H403. <br /> 104. <br /> ((aa t t <br /> FACILIT'YTYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTIONfacility located on Indian Reservation oraos. <br /> 3.FARM ❑ 4.PROCESSOR 6.OTHER lands? ❑ 1.Yes X 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4m <br /> v, I i n �- �, P NE isif - 4oa. <br /> L <br /> MAILING ADDRESS <br /> / 4 Cf <br /> ^ __ 409. <br /> CITY <br /> Oto. STATE _ 411. ODE ZIP C412.�� <br /> • III. TANS f1PERATk'�It;I11TI!EIRMATY?�N <br /> TANK OPERATOR NAME ' <br /> 4za-1. PHONE 428-2. <br /> MAILING ADDRESS aza 3 <br /> k�i L Q � 6 <br /> CITY ` 428.4. STATE 428-5. ZIP CODE 428.6. <br /> IV. 'TANK OWNER INFORMATION <br /> TANK OWNER NAME <br /> 414. PHONE 415. <br /> MAILING ADDRESS <br /> 4I6. <br /> CITY 417• STATE Ota. ZIP CODE 419, <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY <br /> ❑ 6.STATE AGENCY azo. <br /> ❑ 7.FEDERAL AGENCY 8.NON-GOVERNMENT <br /> V. BIpAIW OF EQUALIZATION UST STORAGE;FEE ACCOUNT NUMIRR <br /> TY(TK)HQ 44- 16002-7Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421' <br /> VI.PERMT110LDEIt INFORMATION <br /> Issue permit and send legal notifications and mailings to: :9 1.FACILITY OWNER [14.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 /> CERTIFICATION: I Gerd t the Information rovided herein is truef accurate and in full compliance with le al re uirefl <br /> APPLICA IGNAT DATE 424. PHONE <br /> s 1 �n 9 r <br /> AP IC NT NAME(P <br /> ::qAPPLICAN TITLE <br /> - c 1 t <br /> UPCF UST-A Rev.(12/2007) 1/2 www.auldoes.org <br /> 13 <br />