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UNIF[ED PROGRAM CONSOLIDATED FORM f / <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (ChOOk one acm O°ly) 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> Ii FACII.ITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# <br /> (Agency Use Only) <br /> BUSINESSNAME(sameoFAcn.rrrNAME,. B.W..As) / / 3• <br /> l�T�l.�• / l 7 <br /> BUSINESS SITE ADDRESS f� 103• CITY ��• <br /> © LJ Vv"- "-C-4 ►�-A E S-w- mA C 9sa►s <br /> FACILITY TYPE U_.L MOTOR VEHICLE FUELING [12.FUEL DISTRIBUTION 403' Is the facility located on Injian Reservation or 405• <br /> 3.FARM 4.PROCESSOR 6.OTHER Trust lands? ❑Yes o <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME <br /> Ptd '7 3 <br /> MAILING ADDRESS 409. <br /> c2 -1r LJ IM.�vko-c-,P L or,A�,D.E�, <br /> CITY 411 1 STATE 411. ZIP CODE <br /> 411 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR <br /> �^ 428-1. PHONE42&2 <br /> (� ~7 7 42&2 <br /> t� ) � 005 / 7 J -3 J -7 <br /> MAIL G ADDRESS 428-3 <br /> -7 1 r\/\, va,o-L.. Lb4-4j G <br /> C 42&4 STATE 428.5 ZIP CODE 42" <br /> wz- Q C.� � C lam- <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME ala. PHONE 415. <br /> MAILING ADDRESS 1416. <br /> CITY 417. ST ,4 1 418. ZIP 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY 8.NON-GOVERNMENT <br /> V. BOA OF EQUALIZATION UST;STORAGE FEE ACCOUNT NUMBER <br /> TY(np HQ 44- D g 17 Call the State Board of Equalization,Fuel Tax Division,if there are questions. <br /> 421. <br /> VI.PER IIT HOLDER INFORMATION <br /> Issue permtt and send legal notifications and mailings to: OK 1.FACILITY OWNER [14.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DMSION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> 406. <br /> VII.APPLICANT SIGNATURE <br /> CERT ATION: I certify thatoft information provicled herein is trae,accurate,and In fall compUmce with legal requirements. <br /> APPLIqAqr SIGN A DATE424• PHONE 425. <br /> 3--I e--0 55 <br /> APPL NAME(print) 426. APPLICANT TITLE an <br /> rr <br /> UPCF UST-A Rev.(12/2007) <br />