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6 <br />W I Diary villa <br />4 z-ilzr5W 44,.r,1 <br />IFIED PROGRAM CONSOLIDATED FORM keg <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 />(Check one item only) ❑ 3. RENEWAL PERMIT ❑ 6. TEMPORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT <br />I. FACILITY INFORMATION <br />TOTAL NUMBER OF USTs AT FACILITY 41. <br />FACILITY ID # <br />I <br />(Agency Use Only) <br />_ <br />B)S1NESS NAME (ame as FACILITY NAME or DB Doing Business As) 3. <br />LSU �oSP <br />1 E t.1�0�1 Pti_ l TAr I <br />BUSINESS SITE ADDRESS 103. <br />61"15 S , VartRmoN-r iNwt- <br />CITY 104_ <br />LO 1 <br />FACILITY TYPE ❑ 1. MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 403. <br />Is the facility located on Indi eservation or 405. <br />❑ 3. FARM ❑ 4. PROCESSOR 6. OTHER <br />Trust lands? ❑ Yes o <br />H. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407. <br />hon YN()€-moRtP t_ �Osp 1 -me__ <br />PHONE, 408. <br />90 I 3`4 -3 <br />MAILING ADDRESS 409. <br />9-I S V�Prt R. Y`(No YN R U S - <br />CITY 410.STATE <br />411. <br />CODE 412, <br />Lori <br />CPI <br />g59,40 <br />III. TANK OPERATOR INFO ION <br />TANK OPERATOR NAME 428-1. <br />PHONE 428-2 <br />L -OD 1 tN'\o-0oV_1P'1. �VNPITWL- <br />1 -33 L4 -S'+ I <br />MAILING ADDRESS 428-3 <br />-1 �_:) S R I of-, (�On-r f Vvi- <br />CI1'YE� , azs-a 1 <br />STAn CA-42ZIP <br />CODE ,ra 4 0 428-6 <br />U6 <br />IV. TANK OW R'INFORMATION <br />TANK OWNER NAME 414. <br />LbD i r`(1&moet �b ITh C_ <br />PHONE 415. <br />L4 t I <br />MLING ADD 416. <br />Ti S - A t Arno r, -r- ver__ <br />CITY` I 417. 1 <br />OD <br />STATE 418. <br />ZIP COD�� � 410 419. <br />(U0 <br />OWNER TYPE: ❑ 4. LOCAL AGENCY/DIS CT [:15. COUNTY AGENCY 6. STATE AGENCY 420. <br />❑ 7. FEDERAL AGENCY 8. NON-GOVERNMENT <br />V. BOARD OF E , ALIZATION 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 />Issue permit and send legal notifications d mailings to: <br />1. FACILITY OWNER [14. TANK OPERATOR 423 <br />t3. <br />TANK OWNER ❑ 5. FACILITY OPERATOR <br />SUPERVISOR OF DIVISION, SE ION, OR OFFICE (Required For Public Agencies Only) 406. <br />VII. APPLICANT SIGNATURE <br />CERTIFICATION:.Ycertify that the information provided herein is true, accurate, and in full com fiance with legal re uirements. <br />APPLIC SIG E 01 <br />DATE azo. 1 <br />PHONE au. <br />APP CANT NY4E (print)tt ,, � 426. <br />APPLICANT TITLE 427 <br />O w "re- iR- C -u r\'r-R C_tD F_ <br />UPCF UST -A Rev. (12/2007) <br />