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i <br /> UNIFIED PROGRAM CONSOLIDATEDFORM <br /> UNDERGROUND STORAGE TANK -`m <br /> Y OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per 311 <br /> ' ) is <br /> TYPE OF ACTION ❑ 1.NEW PERMIT �a-5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 4 <br /> 90. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT. <br /> I. FACILITY INFORMATION �f <br /> TOTAL NUMBER OF USTs AT FACILITY 404. LI <br /> FACILITY ID# L '( <br /> (Agency Use Only) <br /> BUSINW NAME(Same as FACILrrY NAME or DBA-Doing Baines s) 3' <br /> O <br /> BUSINESS, ITE ADDRESS/ ���%K ` � � U/� �L��' 103 CITY Ml� <br /> FACILITY TYPE �r 1.MOTOR VEHICLE F ELING ❑ 2.FUEL DISTRIBUTION 4031 Is the facility located on Indian Reservation or 4051 <br /> 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? F_]Yes El No <br /> II. PROPERTY OWNER INFORMATION <br /> PROP TY WNER NAME 407. PHONE 411. <br /> MAILING ADDRESS Q <br /> CITY �_4101 STATE 411. ZIP CODF_ <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPE TOR NAME 428-1. PHONE /ate <br /> LY4,ww Fi13 ow A <br /> MAILING ADDRESS 428-3 <br /> CITY 4284 STATE 428-5 ZIP CODE 4'-8 <br /> IV. TANK OWNER INFORMATION <br /> TANK E NAME 414. 1 PHONE 415. <br /> �4- - ( � ) 23 s Y3y <br /> MAILING ADD SS 416. <br /> c sZ <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> OWNER TYPE: ❑ 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}(�[({�13Q 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 and mailings to: ❑ I.FACILITY OWNER X4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> APPLICANT SIGNATURE <br /> CERTIFICA [ON:' c N that a information prov' ed herein is true,accurate in full co pliance with le al re uirements. " <br /> APPLICANT SIG DATE 2 3 6 424. PHONE �� 1-09? <br /> -C� <br /> APPLICANT NAME int) 426. APPLICAN TITLE <br /> L VU rU'UA-(__ A0:1 J, <br /> I Y. <br /> UPCF UST-A Rev.(I2/2007) <br /> 1 <br />