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UNIFIED PROGRAM CONSOLIDATED FORM /ted C' h^-) S <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ L NE W PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 41X). <br /> (Check one item only) I�1.3�WAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> �i+ ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY ''40" FACILITY ID# 2 <br /> -I- 1-1 \\Y • (Agency Use Only) 3 3 Z <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) <br /> R q S Ff e L-L- <br /> BUSINESS SITE ADDRESS 103. CITY u <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING 2.FUEL DISTRIBUTION Is the facility located on Indian Re ion or 40S <br /> El3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? E] 1.Yes o <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> 7 S� 3 <br /> MAILING ADDRESS ,7.7 6-K G- LJ4- N J� 1--pV P-:f 409. <br /> CITY r. 410• 1 STATE att• ZIP CODE! 41'- <br /> ylt-cirZ C- <br /> lam- :- <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 42$2 <br /> MAILING ADDRESS <br /> CITY 4284. 1 STATE 428-5. ZIP CODE 428.6. <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> C3 A- L 10,-T Ti 67 L c: p Q---- <br /> MAILING ADDRESS 416. <br /> S �- rnt-- <br /> CITY an. 1 STATE 418. ZIP CODE 419, <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY 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- D 01 -71:2 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 471' <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 1.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 /> CERTIFICATION: I cer at the infor anon provided herein is true accurate,and in full com liance with legal re uirements. <br /> APPLICANT SIGNATURE DATE _ y Lf PHONE PHONE 4 5• <br /> 7�`�2 <br /> APPLICANT NAME(print) A til c - I �=6 APPLICANT TITLE , 427 <br /> vT <br /> UPCF UST-A Rev.(12/2007)-1/2 www.usidocs.org r <br />