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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 [:15"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 USTs AT FACILITY 1114' FACILITY ID# <br /> (Agency Use Only) <br /> BUSINESS NA (Same a Facility Name or DBA-Doing Business As) 3. <br /> BUSINESS SITE ADDRESS 7 103" CITY 104. <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE ING ❑ 2.FUEL DISTRIBUTION ao3. Is the facility located on Indian Reservation or 405" <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes ❑ 2.No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407" PHONE 408" <br /> MAILING ADDRFvS- 409. <br /> CITY 410. STATE 411" ZIP CODE 4T2. <br /> K� I _A <br /> c�✓- <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR 421-1, P HONE 428-2. <br /> MAILING ADDRESS ( 428-3. <br /> CITY 428-4. STATE, 428-5. 1 ZIP CODE / 428-6. <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME`, / ` ala. 1 PHONE 415" <br /> l!�l7r,�.3ir(���,:s✓ cJ�.v !I ( ) 9��� .� /5 sL� <br /> MAILING ADDRESS 416. <br /> 417. STATE�^ 418. ZIP COD _ 419. <br /> CITY <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(TK)HQ 44_ 1 1 1 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: El1.FACILITY OWNER 4.TANK OPERATOR 423. <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICA N: 1,pCrtifythat the information provided herein is true accurate s d in full compliance with legal requirements. <br /> APPLICAN� SI DATE424- PHONE 425. <br /> 7 IJ 2) ,f/k-1?f <br /> APPLICANT NAME rmt) ,) 426. APPLICAAT Tl7tE / 427 <br /> �Jc ' %^ [ /k4 <br /> UPCF UST-A Rev.(12/2007)-112 �, 1� www.anidocs.org <br />