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REG� <br /> UNIFIED PROGRAM CONSOLIDATED FORM MAR 0 2 2016 <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORM " A <br /> TYPE OF ACTION1.NEW PERMIT El5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT [16.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMITD Q �3 3 5 <br /> L FACILITY INFORMATION �F(',p 51.0 -7,q 7 <br /> TOTAL M JMRFF iISTs AT FACILITY 404' FACILITY ID# <br /> al-XII I (Agency Use Only) <br /> BU$I ESS NAME(SarncuFnCILrIY Nnn,iFmDB -Doing Busines As) <br /> 3. <br /> BUSINESS SITE ADDRESS 103 CITY 104. <br /> FACILITY TYPE ❑ L MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION -403. Is the facility located on Indi eservation or 405. <br /> 3.FARM 4.PROCESSOR N <br /> OTHER / �� Trust lands? ❑Yes No <br /> II. PRO ERTY OWNER INFORMATION <br /> . PHONE 408. <br /> PROPERTY OWNER N 407 <br /> F / cL <br /> MAILIN ADDRESS 409. <br /> CITY 410. STATE 411. 1 71P COMM 412. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME �+ <br /> 828-1. PHONE 428-2 <br /> ti/C l vo aCC�r�� i v�C l'y'�QlF2 L (. ) <br /> MAILING ADDRESS /W <br /> / W iz3-3 <br /> oV G <br /> CITY 4284 STATE 428.5 ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> PHONE fits. <br /> TANK OWNER NAME ata. (Z <br /> �� � _ C � <br /> MALT TNG ADDRESS 4167 <br /> CITY 4 . STAT ate- ZIP CO y 419. <br /> S��G �).�.� s zL <br /> OWNER TYPE: .4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY 1-20.NON-GOVERNMENT <br /> V. F OARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421 <br /> VI.PERMIT HOLDER INFORMATION <br /> 427 <br /> Issue permit and send legal notifications and mailings to: ❑ FACILITY OWNER ❑ 4.TANK OPERATOR <br /> TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> _ VII.APPLICANT SIGNATURE <br /> CERT TION: I c at the information provided herein is true,accurate,a4d in ll compliance with legal requirements. <br /> ` APP CANT iGNA DATE � 424 PHONE 4u <br /> ftr/CANf A 8267Aovl ANT TITL}F 827 <br /> UPCF UST-A Rev.(1212007) <br />