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UNIFIED PROGRAM CONSOLIDATED FORM / <br /> UNDERGROUND STORAGE TANK S G v� <br /> OPERATING PERMIT APPLICATION - FACILITY INFORMATI <br /> (One form per facility) gf 4 <br /> TYPE OF ACTION ❑ I.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' I FACILITY ID# _ /� <br /> (Agency Use Only) `� <br /> BUS[N i7 �Y� I / 1 454� 1 L <br /> SSS ME(Same as Facilitv Name or DBA-Doin Business As) �_, �A �7�•?J f�� ; <br /> L�.. TIS M J <br /> BUS ESS SITE ADDRESS 103. CITY 104. <br /> Z_749 " er Cv c, <br /> FACILITY TYPE 2-1.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? ❑ 1.Yes ❑ 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE z 408. <br /> �� ✓���� <br /> M ILING ADDRESS J 409. <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> N5r-6 c N 0A- ?S-j-0.6- <br /> 111. <br /> sIII. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2. <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 /> JII k4 o l (�f) J.3134 <br /> MA MAL G ADDRESS -` 416. <br /> -75 <br /> CITY 417. STAT 418. ZIP CODE 419. <br /> as' <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- 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: XI.FACILITY OWNER ❑ 4.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 /> CERTIF ION: I certify that the information provided herein is true accurate and in full compliance with le al requirements. <br /> APPLIC NT NATURE DATE �, 424. PHONE 425. <br /> APPLIC N E(print) 426• APPLICANT 427 <br /> r � <br /> UPCF UST-A Rev.(12/2007)-t/2 www.unidocs.org <br />