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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 ❑ I.NEW PERMIT 1!6 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400 <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 :*1 404 1 FACILITY ID# _ _ �j I <br /> b1 (Agency Use Only) I <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. <br /> 'o« c��kb Fe,,W 76ke- mini MQ <br /> BUSINESS SITE DRESS 103. CITY 104. <br /> `6Sb CaLt,) r c(Lkb IV S�c�c f c� r u� <br /> FACILITY TYPE �"I.MOTOR VEHICLE FUELING El2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or aos. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 409. <br /> 5 A �'L o(-e. �o <br /> MAILING ADDRESS 409, <br /> CITY 41°. STATE 411. ZIP CODE 412. <br /> Wl C (I +V-&qC e_-� '7S 3 3 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> to etv ti YetI.,L4 <br /> MAILING ADDRESS 4293 <br /> 4Z E <br /> CITY 4284 1 STATE 428-1 1 ZIP CODE 428-6 <br /> 6 'n <br /> IV. ,TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> 2 SS el L -e ( CDP 5-Z <br /> MAILING ADDRESS <br /> 416. <br /> -'-/ y �- 6 Pea C lk re-"( <br /> CITY alz STATE 418. ZIP CODE 419. <br /> 1w1 -til e �� e:�Oa �.�` 3 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY ago. <br /> ❑ 7.FEDERAL AGENCY r8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 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 /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify thal th5onf9rmation rovided herein is true,accurate,and in full com liance with legal re uireme a <br /> APPLICANT SIGNATURE DATE 6 424. PHONE S� r-=+x 425. <br /> APPLICANT NAME(print) 0 426. APPLICANT ITLE C=3 27 <br /> 040 <br /> UPCF UST-A Rev.(12/2007) . <br />