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0 0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY I r M J'Ub . <br /> (One f per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT 5.CHANGE OF INFORMATION ❑ 7.PE NT F�ACILITY CLOSURE aoo. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# 1 1 _ 1 I I 1 _ 1 I II <br /> (Agency Use Only) 1 C� <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. <br /> oct CL�b oa C�� mi r11 1��t <br /> BUSINESS SITE 103. CITY 104.DRESS Cly <br /> C6510 Cc�tcn r CILiJ WUqS �O ' <br /> FACILITY TYPE JSI.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408. <br /> Fq stz I PA L d-ek- C'5G z - 9s a <br /> MAILING ADDRESS 409. <br /> T 4 p Cly Yd <br /> CITY 410. 1 STATE 411. ZIP CODE 412. <br /> Uvk an +'e- C+' < ✓ � .3 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME a2aa. PHONE a2s-2 <br /> MAILING ADDRESS 428-3 <br /> CITY 428-4 STATE 428-s ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. 1 PHONE 415. <br /> zeL- e_ (2v1) <br /> MAILING ADDRESS <br /> 416. <br /> 'e-r <-�' S- 6 Pea c�, Y'c,� <br /> CITY 417. STATE 418. ZIP CODE alv. <br /> 11" e�oa <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY _ �L,8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue pennit and send legal notifications and mailings to: El1.FACILITY OWNER4.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 /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify thaf thq?inf9rTnati9n#rovided herein is true,accurate,and in full com liance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424 PHONE 425. <br /> a (3 ( 2, s���Z 1 <br /> APPLICANT NAME(print) ®® 426. APPLICANTTITLE 427 <br /> LO <br /> UPCF UST-A Rev.(12/2007) <br />