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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK z- <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION Ir <br /> (One form per facility) <br /> TYPE OF ACTION El 1.NEW PERMIT X 5.CHANGE OF INFORMATION n 7.PERMANENT FACILITY CLOSURE 400 <br /> (Check one item only) 0 3.RENEWAL PERMIT M 6.TEMPORARY FACILITY CLOSURE [3 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OFSTs AT FACILITY 44 1 FACILITY ID# <br /> I (Agency Use Only) <br /> BUSIISS NAME(s=,.FACaffY HAKE or DBA-Doing Businm As) <br /> s. <br /> himw 0.1rib 6mat I-SiLl Alm lybr103. CITY 104, <br /> BUSINESS SITE AWRESS <br /> 403. 405, <br /> FACILITY TYPE I.4TOR VEHICLE FUELING E32.FUEL DISTRIBUTION Is the facility located on Ithan Reservation or <br /> 3.FARM 0 4.PROCESSOR 0 6.OTHER Trust lands? [I Yes 19 No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407- PHONE 2408. <br /> f5 2, <br /> MAILING ADDRESS 409. <br /> -g0c) EQ�lx AN-1 410. 411, 411 <br /> CITY STATE ZIP CODE <br /> CA, <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428x• PHONE 129-2 <br /> ZO <br /> MAILING ADDRESS 428-3 <br /> I Kfk 0CL064 ELL 61 Qd <br /> CIT4428-4 ] STAp 428-5 Z[P CODE 428-6 j <br /> Y ---Ij _A <br /> � K'W� A - <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAjvffi 414. PHONE <br /> 2- <br /> MAILING ADDRESS 416. <br /> 4'm Pea-ck Avf- <br /> CITY 412 1 STATE 418. ZIP COD 419. <br /> CA ilt33 7 <br /> OWNER TYPE: n 4.LOCAL AGENCY/DISTRICT 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY JK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER DffORMATION <br /> 423 <br /> Issue permit and send legal notifications and mailings to: 0 1.FACILITY OWNER 4.TANK OPERATOR <br /> C3 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VH.APPLICANT SIGNATURE <br /> CERT1FtCAV0ri:,f fy tfiSt the informatioi provided herein is true,accurate,and in full compliance with legal regairements. <br /> APPLIC G DATE 424. PHONE 425, <br /> 2- <br /> -TjTP-LIC AS (p;int) -1 A 416. APPLICANT TITLE Q17 <br /> duly e;+,y u <br /> UPCF UST-A Rev.(12/2007) <br />