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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) LP <br /> / <br /> ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE El9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION 2L <br /> TOTAL NUMBER OF USTs AT FACILITY 404FACILITY ID# <br /> (Agency Use Only <br /> BUSINESS NAME(Same as FAC1LMY NAIVE or DBA-Doing Business As) ' <br /> 14:1 > -- <br /> BUSINESS SITE ADDRE6S 103. CITY 1044 <br /> FACILITY TYPE [11.MOTOR VEHICLE FUELING El2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ❑No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4(,7 PHONE 408. <br /> MAILING ADDRESS 1 a09. <br /> CITY 410, STATE 411. 1 ZIP CODE 412. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> c <br /> MAILING ADDRESS 428-3 <br /> CITY 4284 STATE 428-5 ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415. <br /> MAILING ADDRESS 416. <br /> CITY 417, 1 STATE 418. ZIP CODE 419. <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: I.FACILITY OWNER ❑ 4.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 SIGNATURE DATE 424. PHONE 425. <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> UPCF UST-A Rev.(12/2007) ��J J / 3( T L.A <br />