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4 j <br /> qA <br /> 1A�Zj n7 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.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 /> t <br /> I FACILITY,INFO.RM�ATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404 FACILITY ID# } <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name o/DBA-Doing Business As) 3. <br /> S oc o umpitm sckooL <br /> BUSINESS SITE ADDRESS 103. CITY 104. <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? ❑ 1.Yes [Q 2.No <br /> IL. PROPERTY QWNER INFORMA TION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> o l� c O <br /> MAILING ADDRESS 409. <br /> 14 <br /> CITY l l 410. 1 STATE 411. ZIP CODE 412. <br /> Q <br /> it. T4NK~0R INFi`RMATIO�T <br /> TANK OPERATOR NAME 428-1. PHONE 428-2• <br /> Dq(� Co 41 4315ro <br /> MAILING ADDRESS 428-3. <br /> Q,O . box 91 <br /> CITY IMA STATE 42a s. ZIP CODE 428-6. <br /> S�Qzl��01� cq. q 5 ao1 <br /> IV. TAIOW-NER INFORIYIATION . <br /> TANK OWNER NAME 414. PHONE 415. <br /> ( ) 9 o 6 <br /> MAILING ADDRESS at6. <br /> CITY 417. STATE418. ZIP CODE 419. <br /> OWNER TYPE: 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ &NON-GOVERNMENT <br /> ' V..BOARD OF EQCTAiI�ATiON UST STORAGE FEE ACCOUNT�1iLJMTfER;, <br /> TY 9K)HQ 44- 0 Q _ Equ I Tax Division,if there are questions. 421. <br /> Call the State Board of Equalization,Fuel <br /> �'I.PERIVlIT HOLDER II�TFORMA.TI(�N - <br /> Issue Permit and send legal notifications and mailings to: 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> 423. <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406' <br /> V1I.APPLICANT SIGNATURE <br /> CERTIFICATION: I certi fm that the information provided herein is tree accurate and in full com fiance with legal requirement s. <br /> APPLIC SIGNDATE 424. PHONE 425,_ <br /> APPLICANT NAME(print) 426. APPLICANT TITLE <br /> •-- <br /> UPCF UST-A Rev.(12/2007)-l/z www.unidocs ory <br /> £TO/Zoog XVa 6S :OT OHS 60OZ/40/90 <br />