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UNIFIED PROGRAM CONSOLIDATED FO <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 /> (Chea ow mcm only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L FAIIITY IIY�'ORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY FACQ.ITY ID 11 1. <br /> (Armes use 0*) - - <br /> BUSINESS NAME(same a mcnnY mw a DRA-Duke nares m) 3• <br /> BUS SS SIZE ADDRESS 103• CITY 104. <br /> -7/ G Si Ste_t :7 <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL.DISTRIBUTION 403' h the facility located on Indian Reservation or 40' <br /> 3.FARM 4.PROCESSOR El 6.OTHER Trot!sods? ❑Yes ❑No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4W PHONE p 4W <br /> MAILDiiG DRE,SS 409. <br /> 719 <br /> 5 <br /> CITY 410, STATE 411. ZIP CODE 412 <br /> qr-2-6 z- <br /> TIL 'ANKOPERiTOR INFORMATION <br /> TANK OPERATOR NAME 429"1• PHONE <br /> 17 Sf- <br /> MAILIM ADDRESS 429-3 <br /> 7/3 4/ <br /> CITY 4294 STATE 428.5 IIP CODE <br /> 2. <br /> IV .TANICOWNER EWORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> f*/,W) <br /> MAILIl40 ADD RES 416. <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> qr <br /> OWNER TYPE. ❑ 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 421L <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF$QUALIZATIONUSTSTORAGE Eric ACCOUNT NOIVIBER=' <br /> TY )HQ 44- GU the Stade Board of Egmhmbm Fu d Tax Diviam,if these are gaesdoas. 4z1. <br /> VL'PERWr HOLDER'.INFORMATION <br /> Issue permit and Bead legal nodficamm and amitmgs to: •n.FACMnY OWNER ❑ 4.TANK OPERATOR 423 <br /> Q-3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For I Mic Agencies Only) 40 <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is lra accwa aald in fill coiumipUamcewith leld regidrementL <br /> APPLICANLMNATURE DATE 424. 1 PHONE 425• <br /> Qjg1 �5�19//u <br /> APPLICANT NAME(print) 426. APPLICANT T= 427 <br /> UYGF U3T-A RaV.(1112000 <br />