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UNIFIED PROGRAM CONSOLIDATED FORM 7 �� <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION -FACILITY INFO ATI?N 2 J�' <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANE FACILITY CLOSURE 4 <br /> (Check one item only) ❑ 3.RENEWAL PERMIT El 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANS F R PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMB OF USTs AT FACILITY 404' FACILITY ID# _ t <br /> (Agency Use Only) f � � <br /> BUSINESS NAME(Sam s Facility Name or DBA-Doing Business As) 3. <br /> (ty J IS E/CA, 4 FU v D <br /> BUSINESS SITE ADDRESS 103 CI 104. <br /> 104. <br /> FACILITY TYPE OLMOTORV ICLE FUELING El2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM EIN4,.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes M 2.No <br /> PROPERTY OWNER INF RMATION <br /> PROPERTY OWNER NAME 407. 1 PHONE 408. <br /> Cc,D�2 AS �L (�M �t P 7o9 'Z 3 9 - 4 T q 7 <br /> MAILING ADDRESS 4°9. <br /> CITY Oto. STai i. ZIP S33 412. <br /> III. TANK OPERA*R INFORMATION <br /> TANK OPERATOR NAME 428.1. PHONE 428-2. <br /> P�x� ���� Oil, > 833 <br /> MAILING ADDRESS 426-3. <br /> `l? -L CO CA K0 <br /> CITY 426.4. 1 STATE N2Q ZIP CODE 426'6. <br /> �UI�N eA STT 7 <br /> IV. TA OWNER INFORMATIO <br /> TANK OWNER NAME 414. PHO 4ts. <br /> � u t P (2 0 2 3� - ��( 7 <br /> MAILING ADDRESS 416. <br /> 8?,o PENC-1�1 ?� <br /> 417. STATES^ 418. ZIP CODE E 419. <br /> CITY WTE-C Az I 6A I J <br /> OWNER TYPE: ❑ 4.LOCAL AGENC /DISTRICT [❑/5.COUNTY AGENCY [-16.STATE ENCY 420. <br /> ❑ 7.FEDERAL AG CY L{8.NON-GOVERNMENT <br /> V. BOARD OF OUALIZATION UST STORAGE FEE ACCOUNT NUMBS <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are que ons. 421. <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notification Ind mailings to: ❑ 1.FACILITY OWNER 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SE ION,OR OFFICE(Required for Public Agencies Only) <br /> VII.APPLICANT SIGNATURE , <br /> CERTIFICATION: I that the information provided herein is true,accurate,and in full cora liaxce with legal requirements. <br /> A�[CANT SIFiGNATU (TE _ �� 424PH(2,NE -- 9 415. <br /> APPLICANT/NAME( rint) 426. APPLICANT TITLE -,..: 427 <br /> PN �oL� <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />