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L & 0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT x 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE aoo. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF tJSTs AT FACILITY 404' FACILITY ID# <br /> !1 (Agency Use Only) L I <br /> BU$ SS NANIE(Same as FACI M NAME or DBA—Doing Bmin=As) <br /> BUSINESS SITE AQVRESS 103, CITY 104, <br /> FACILITY TYPE 1. TOR VEHICLE FUELING [I2.FUEL DISTRIBUTION 40' Is the facility located on I dian Reservation or 405' <br /> 3.FARM 4.PROCESSOR 6.OTHER Trust lands? ElYes V No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME S07 PHONE lads. <br /> ocic <br /> MAILING ADDRESS 409` <br /> '-I <br /> CITY 410• STATE all. ZIPCODE ail. <br /> �, �s <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1' PHONE 428-2 <br /> r ( 2&1-loS VD <br /> MAILING ADDRESS 4'-8'3 <br /> (6N <br /> CIT t A a'8� STAT�� 42M ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME ala. PHONE 6241.:. <br /> o SS e-I F,t d'er (269 4-7 Zoq5 i <br /> MAILING ADDRESS 416. <br /> 4,m) Peek Avc <br /> CITY <br /> /'` <br /> /y� ' n - an. STAT 418. ZIP C�t 3 3 7 419, <br /> OATeco,_ 11 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY i1r�,r 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44_ 1 1 1 1 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 and mailings to: ❑ 1.FACILITY OWNER 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> sob. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTjFtCAjtj0rjtXWtify tfigt the informadoi provided herein is true,accurate,and in full compliance with legal requirements. <br /> PHONE ONE 425. <br /> APPLIC G DATE G—�rD 2v(h � Z'Oq q 2 <br /> APPLIC AME(punt) 416. APPLICANT TITLE t v a'7 <br /> QS SQ t,Qf2-r 1 2 O w r e-r- <br /> UPCF UST-A Rev.(12/2007) <br />