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002185 <br /> UNIFIED PROGRAM CO <br /> NS <br /> OLIDATED F <br /> O <br /> UNDERGROUND STORAGE TANK <br /> OPERITING PERMIT APPLICATION—FA <br /> C <br /> I <br /> L <br /> I <br /> T <br /> Y <br /> M <br /> INFOION(One form per facility) <br /> TYPE OF ACTION El I NEW P IT 5.CHANGE OF INFORMATION 0 7 PERMANENT FACILITY CLOSURE a00' <br /> (Check one item only) 0 3.RENEWAL PERMIT ❑ 6,TEMPORARY FACILITY CLOSURE 0 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF STs AT FACILITY ... FACILITY ID# T 1-1 1 . 1 1, LLL <br /> 1 (Agency Use Only) <br /> BUSIS N (Same.!'FACRM NAME.DBk-Doing <br /> MPri'm -1. I tu fd. Aim Mar J 103, C 104.- <br /> BUSINESS SITE AWRESS <br /> I LL rhoa�u 403. 405. <br /> FACILITY TYPE I.MbTOR VEHICLEFUELING ❑ 2.FUEL DISTRIBUTION Is the facility located on I dian Reservation or <br /> 3.FARM ❑ 4.PROCESSOR 6.OTHER Trust lands? ❑Ye s IRNO <br /> 11. PROPERTY OWNER rNTORMATION <br /> PROPERTY OWNER NAME 407, PHONE <br /> � _1 <br /> 3c/,0 409. <br /> MAILING ADDRESS <br /> CITY a10 STATE 411, ZIPCODE 411 <br /> IH. TANK OPERATOR INFORMATION . <br /> TANK OPERATOR NAME 428-1. PHONE <br /> MAILING ADDRESS 428:3 <br /> 42a t 'AT 4-28-5 71P CODE 42M <br /> CITY _Q <br /> IV, TANK OWNER INFORMATION <br /> TANK OWNER NlAME ara. PHONE IZ414 <br /> MAILING ADDRESS <br /> 4$,6® Peo_ck Avf- <br /> CITY417. STATE 418. ZIP C 4�33 419. <br /> /ARA�tCC;i— C 7 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT 5.COUNTY AGENCY C3 6.STATE AGENCY 420. <br /> ❑ 7 FEDERAL AGENCY S.NON-GOVERNMENT <br /> V. BOA"OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER. <br /> TY(TK)HQ 44 cad]the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> 423 <br /> Issue permit and send legal notifications and mailings to: 0 1 FACILITY OWNER 4.TANK OPERATOR <br /> 0 3.TANK OWNER [1 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CER C 01y. wtify t it the WorrnaqoAprovided herein is true,accurata,and in full coma fiance with legi requirements. <br /> APPLIC DATE 424. PHONE 425. <br /> 416. APPLIQWrr TITLE an <br /> _T?_PLICA <br /> AM (pFint) <br /> ae�+y <br /> as sel <br /> UPCF UST-A Rev.(I V2007) <br />