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UNIFIED PROGRAM CONSOLIDATED FORM 6(I Z3 d <br /> UNDERGROUND STORAGE TANK ` <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT R-I'CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(same asFAcmnyNAME orDt3A-Dome Iwft ssn_sj , �,. 3• <br /> BUSINESS SITE ADDRESS (�(S 1J��1 tc3• CITY 104• <br /> FACILITY TYPE 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? ❑Yes ErNo <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME ri�L S� ^ /L (L Q (� PHONES Z'� aos• <br /> MAILING ADDRESS L 409• <br /> 12a.5 J <br /> CITY 410• 1 STATE all• ZIP CODE 412. <br /> C�•c 5 2 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME �� � � aza-t• 1 PHONE 0� ) ���� 1 w � 1, 1 428-2 <br /> MAILING ADDRVI � l 428-3 <br /> CITY 428a 1 STATE 428-5 1 ZIP CODE428.6 <br /> 1C-R °L s <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME414. PHONE 415. <br /> MAILING ADDRESS 416. <br /> CITY L� Ott. STAT�iAgr- als. 1 ZIP CODE J,Z` _ 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY Oxo. <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 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: Wt.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) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate,and in full com liance with leeal requirements. <br /> APP SIGNATUREDA( 424. pj Nk 425. <br /> APP ANT NAME(print', 426. APPLIC 427 <br /> G v a i' <br /> UPCF UST-A Rev.(12/2007) V �J� �t <br />