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UNIFIED PROGRAM CONSOLIDATED FORMa /�� UNDERGROUND STORAGE TANK (� K/�" OPERATING PERMIT APPLICATION-FACILITY INFORMATION (One form per facility) [TYPE 7OFACTIO N ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION 400. (Check one item only) ❑ 7.PERMANENT FACILITY CLOSURE ( ] 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF USTs AT FACILITY 40 J�FACILITY 3 ID# ency Use Only) JC BUSINESS NAME(s a as FACILITY NAME or DBA-Doing Business As) �kP, r^SS AJDW-�T 6 3. BUSINESS SITE ADDRESS 103, CITY �i y Soy TI- A4 A/ � STSr; ,KAA-1 coq 10+ FACILITY TYPE [ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or 405. 3.FARM 4.PROCESSOR M 6.OTHER Trust lands? ❑Yes No II. PROPERTY OWNER INFORMATION PPROPERTYER NAME 407 PHONE 408. Z�f 239ESS ao9. SO,-!T n �� SiF 3c CITY 410 STATE 411 ZIP CODE 412. III. TANK OPERATOR INFORMATION TANK OPERATOR NAME 428-1 PHONE 428.2 A P&P 7-/,/ L('149 ( ) MAILING ADDRESS 428-3 CITY 4294 STATE 428-5 ZIP CODE aze� IV. TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 MAILING ADDRESS 416 CITY 417 STATE 419. ZIP CODE 419. OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. ❑ 7.FEDERAL AGENCY 8.NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. +21. VI.PERMIT HOLDER INFORMATION Issue permit and send legal notifications and mailings to: 1.FACILITY OWNER ❑ 4.TANK OPERATOR +23 ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 49 VII.APPLICANT SIGNATURE CERTIFICATION: I ceT the information rovided herein is true,accurate,and in full com Hance with legal requirements. APPLICANTSTGNATURg, DATE 5-//C/�g az4 PHONE +zs. APPLICANTNAME(print))) � C �G'/v LJ5'' r 4z6. APPLICANT TITLE 427 /� M� G/� % ow,w ,2 UPCF UST-A Rev.(12/2007)