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UNIFIED PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-FACILITY INFORMATION (One form per facility) 4. TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE (Check one item only) REIEWAL,PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER F USTs AT FACILITY 404' FACILITY ID# 777 _ 1' (Agency Use Only) BUSINESS NAME(game asFACILMYNAVE or DBA-Doing +Business As) 3. �✓ m\e BUSINESS SITE ADDRESS 103. CITY 104. 601 C. vj Lob 1 5� o FACILITY TYPE X 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403 Is the facility located on MOO Reservation or 405. ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes No II. PROPERTY OWNER INFORMATION PROPEr OWNER NAME PHONE 408 MAILING ADDRESS 409 __:S K- VkOLkIE Wit'. CITY 410. 1 STATE 411. ZIP CODE 412. e " III. TANK OPERATOR INFORMATION TANK O ERATOR NAME 428-1. 1 PHONE 428-2 MAILING ADDRESS 1 ® 428-3 CITY 428.4 STATE 428-5 1 ZIP CODE ® 428-6 O L4 IV. TANK OWNER INFORMATION TANK OWN AME 414. PHONE 415. MAILING ADDRESS � 416. CITY rrD 417. 1 STATE 418 1 ZIP CODE 419. OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. ❑ 7.FEDERAL AGENCY 8.NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. VI.PERMIT HOLDER INFORMATION Issue permit and send legal notifications and mailings to: 1.FACILITY OWNER ❑ 4.TANK OPERATOR azs Q 3.TANK OWNER ❑ 5.FACILITY OPERATOR 406. SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) VTI.APPLICANT SIGNATURE CERTIFICATION: I cert' that the informisAon REovided herein is true,accurate,and in full compliance with legal re uirements. APPLICANT SIGNATUREt_[ { DATE 4za. PHONE a °}1l1 �C9 �'/ �� e) APPLICNA �109PP a 426. APPLICANT TITLE 427 UPCF UST-A Rev.(12/2007)