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t <br /> t Ito <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND S'T'ORAGE TANK <br /> OPERA'T'ING PERMIT APPLICATION-FACILITY INFORMATION <br /> ()ne form per faeiliry) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT )K 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY OSURE 8°0 <br /> (Check one iters only) ❑ 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I, FACILITY INFORMATION <br /> TOTAL NUMBER OF UST5 AT FACILITY 4°4. FACILITY ID# <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(Same-FACILITY NAN E Or DBA-Doing p0ait�As) 3 <br /> ivC n� �c�7 OLE//M .ZN C <br /> 13USINESS SITE ADDRESS "3. CITY too. <br /> / d 5�fy1/rte iQr.C' 11�TFCAA <br /> FACILITY TYPE I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION Op}' Is the facility located on Indiar Reservation or 40.5. <br /> -2 FAD%A 4,PROCESSOR 6.OTHER Trust I*$? ❑Yes lo <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME PAUL- BAIVL& 407. <br /> PHON +°S. <br /> Q-0;j ' 4 <br /> MAILING ADDRESS 409. <br /> AV Ir <br /> CITY Oto. STATE 411 ZIP CO E 412. <br /> MAN _CA CA I 95336 <br /> YII. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. piI0N6 428-1 <br /> PWL BA��is <br /> MAILING ADDRESS <br /> ( �l �fpS�Mr .DYE <br /> i <br /> CITY 428-4 STATE_ 428-5 1 ZIPCODE QS-6 <br /> MANTE:ca Ca 533C <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. 1 PHONEi a1s. <br /> MAILING ADDRESS 416, <br /> I��1 YoscMr,� M e- <br /> CITY 417. STATE 418. ZIP CODs 419, <br /> M A NIT--cA CA q 5 33 <br /> xOWNER TYPE: 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGEN CY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there a questions. d21 <br /> VI.PERMIT HOLDER INFORMATION <br /> 15sue permit and send legal notifications and mailings to: ❑ 4.TANK OPER OR 423 <br /> D 6 Ss ❑ 1.FACILITY OWNER <br /> I.TANK OWNER ❑ 5.FACILITY 0 BATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406 <br /> VIL APPLICANT SIGNATURE <br /> CERTIFICATION: I cerci hat the i rmation provided herein is true,accurate and in full compliance with le al regi iirements. <br /> APPLICANT SIGNATURE 4 DATE 424. PHONE 3 <br /> AA,41,12—2LF �Olti 1a P.3 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE n 427 <br /> UPCIi UST-A Rev.(1211007) <br /> i <br />