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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-FACILITY INFORMATION (One form per facility) TYPE OF ACTION L NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400, iCneck one item uuiy) ❑ 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID 4 2. (Agency Use Onl)) BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3' Lir i �ry BUSINESS SI FE ADDRESS 103, CITY 104 FACILITY TYPE E2 I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403, Is the facility located on hndian Resenation or 405- 0 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes L"No II. PROPER T Y OWNER NER INFORINILA TION' PROPERTY OWNER NAME 107 PHONE 408- MAILING ADDRESS 409 CITY 410 STATE 411, ZIP CODE 412, III. TANK OPERATOR INFORMATION TANK OPERATOR NAME 428-1 PHONE 428-2 MAILING ADDRESS 428-3 CITY 428-4 STATE 428-5 ZIP CODE 428-6 e✓! ii. IV. TANK OWNER INFORMATION TANK OWNER NAME 414 I PHONE 415. J;;->7 MAILING ADDRESS 416' CITY 417, STATE 418, ZIP CODE 419. OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 ❑ 7.FEDERAL AGENCY [3'-8.NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44-7 1 1 1 1 1 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. VI. PERMIT HOLDER INFORMATION ,—, Issue permit and send legal notifications and mailings to: 2-'I.FACILITY OWNER ❑ 4.TANK OPERATOR 423 ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR 406. SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) VII.APPLICANT SIGNATURE CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with ie al requirements. APPLICANT SIGNATURE DATE / 424 PHONE 425 APPLICANT NAME(pnnt) v 426. APPLICANT TITLE 427 UPCF UST-A Rev.(12/2007)