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FROn-: CANEPA'S FAX NO. : 4786342 Jul. 31 2009 04:37PM P2 <br /> v„ Jim LVV7 &A-L 14: Sb ?AZ AT (33433 64C END . <br /> ®003/008 <br /> r► <br /> UNIFMD PROGRAM CONSOLIDATED FORM \—fps % <br /> f <br /> UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-FACILITY INFORMAT(One form per facility)TYPs:OFACTION Q LNEWPERMI i Q 5.CHANGE OF INFORMA'T'ION © T.PF,ftIyAPI£NTFACILT7YC <br /> © 3.RENEWAL PERMIT Q 6,TEP4PORARY rACILITY CLOSURE Q 9.TRANSFFE2 PERMFT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF LSTs ATFACILTTY FACILITY1134 <br /> (Agency Use On1j) FT (e',;,, <br /> WSIMiSS NAME Mme arIl+adUlly.Paste Or LFRA•-DO1 Il�ailmers Asj s. <br /> BUSINESS SITE ADARESS :ra CITY <br /> FACILITY TYPE 2:I.MOTOR VEHICLE P'UELINC [12.FUEL DISTRIBUTION IS the fac=[;Ey located on Indian Reservation or 403' <br /> 3.FARM 4.PROCI.SSOii [36.OTHER T3ust lauds? Q 1.Yes 0 2,Na <br /> H. PROPERTY OWNER INFORMATION <br /> FROPF3m OWNER RkmE /] 4". PHONE C +pg <br /> MAII,INCI ADDRESS <br /> CITY alo. STAlt 411. 1 2IPCODE a,z. <br /> I <br /> III. TANK OPERATOR INFORMATION <br /> TAMC OPERA R NAME a:st. PHOAT <br /> MAILING ADDRESS <br /> CITY X42". STATE +rss. <br /> /+ ZIPCODpe 4za-s. <br /> IV. TANIG OWNER INFORMATION <br /> TANK OWNER,NAME a:s. PIdONE ata. <br /> MAILING ADDRESS <br /> S-3 � <br /> CITY l/1676k C'a 41 srATE ......__ �,$ ZIP Cone f, Q 40. <br /> OWNERTYPE: Q 4.LOCAL AGENCY01STRICT Q S.COUNTY AGENCY 6.STATE AGENCY 4-& <br /> ❑ 7.FEDERAL AGENCY 8.NON40VERNMSNr <br /> _ V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUIVIOM <br /> TY(TK)HQ 44- 51 17 Call the State Board Of Equaliaution,Fad Tax Division,if them-sre question. 4Zt' <br /> VI.PERMIT HOLDER INFORMATION <br /> lane pennli end send legal notiPrstib,tA W mnailinp to: M 1,FACILITY OWNER Q 4.TANK OPERATOR 423. <br /> 0 3,TANK OWNER 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION.SECTION,OR OFFICE!Rcquin?d fbrPubfic Ag-aes Onfy,) 40. <br /> VII.APPLXCANT SIGNATURE <br /> CERTIFICATION, 1 gerfift that the informalloq vrevkW herein is true accurate,sad in fall compftlice with legidr utrement& <br /> APPLICANT SIGNATUM DATE 4•.i• P14ONE a's <br /> G <br /> APPLICANT NAM fi pstni APPLICANT TrrLk dzi <br /> Vem �' Aager- <br /> a <br /> uFCR us-r-n I4,cv.(xxrA07)-1/2 www.thnldoea.ors <br /> Air, <br />