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I & __4 <br /> \'_J v <br /> UNIFIED PROGRAM CONSOLIDATED FORM -7-30 <br /> UNDERGROUND STORAGE TANK � ��//3 v p. <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATIONf / <br /> (One form per facility) <br /> TYPE OF ACTION 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one hem only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FA LITY 404. FACILITY 1D# <br /> (Agency use Only) <br /> BUSINE NAM�LSame as Facility Name r DBA-Doing Business As) 3. <br /> get -Linx bo <br /> BUSINESS SITE A DRESS � W 103. CITY �104.r-I <br /> S_>�C4 <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indiatyiteservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes 02.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. f PHONE 408. <br /> �, o �- 23 1 � <br /> MAILING ADDRESS 409. <br /> CITY 410. 1 STATE + ZIP CODE 412. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2. <br /> AL " np�3K `7 jo Zia <br /> MAILING ADDRESS 428-3. <br /> kbL'�ur' _ <br /> CITY � � azs-a. STATE 42a-s. ZIP COi E �� � 428-6. <br /> c4t� c � 9 � <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME _ 414. PHONE 415. <br /> Rkc) w ,r,(_ ($31 ) v 2236 <br /> MAILING ADDRESS 1 1 OG PIC) 416. <br /> CITY ��` a1�. STATE ala. ZIP CODE � 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5 OUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ON-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 questigpw. ' <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 1.FACILITY OWNER <br /> ❑ 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 6. <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 SIGN DATE 424. PHONE 425• <br /> `-7 ,0)09 <br /> X31 1 0 123 0 <br /> APPLICANT AME 'nt) 426. APPLICANT'TITLE 4n <br /> 1 A)>J <br /> UPCF UST-A Rev.(12/2007)-U2 www.unidocs org <br />