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C � J <br /> UNIFIED PROGRAM CONSOLIDATED FORM p 2°fcc <br /> UNDERGROUND STORAGE TANK r <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATIO <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT IN 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9. <br /> I. FACILITY INFORMATION n� - <br /> TOTAL NUMBER OF USTs AT FACILITY 4oa. FACILITY ID#41 _ pp <br /> (Agency Use Only) 'j ti tp <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> PN5Ji,i H <br /> BUSINESS SITE ADDRESS 103. CITY W 104. <br /> '11,lpo kpsdowS7'VC*-Co,1 <br /> FACILITY TYPE 1.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? ❑ 1.Yes 2.No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 403 PHONE 408. <br /> (;ror� <br /> Pola.►��e. 2n Bo»sc. 10 <br /> MAILING ADDRESS 409. <br /> P'.O• �o�r 6q <br /> CITY 410. [STATE 411. ZIP CODE 412. <br /> g To mak?ori e A 4'9.2-14 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME , azs 1. PHONE 428-2. <br /> 1 &WK T-KCr ( coq ) 477 - -284Aj <br /> MAILING ADDRESS 428-3. <br /> � 6 G a {.au!�r So�cyA.n►r•.f7`d <br /> CITY STATE 429-5. 1 Z1P CODE 429-6. <br /> 5To8-Ictort <br /> CA q,S*1 b <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> A477- 2VA19 <br /> MAILING ADDRESS 416. <br /> $6 L o 1,o�•r 0,cra,�s..�7o <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY 4 8.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) <br /> VII.APPLICANT SIGNATUREA. <br /> CERTIFICATION: I certify that the inl(o oration provided herein is true accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. 1 PHONE #25. <br /> APPLICANT NAME(print) 426- APPLICANT TITLE �" 427 <br /> 7. <br /> UPCF UST-A Rev.(12/2007)-1/2 www.nnidocs.orgElm <br /> �' <br />