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ti Q� rL>/l/U <br /> UNIFIED PROGRAM CONSOLIDATED FORM <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 /> (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' 1 FACILITY ID# _ L <br /> (Agency <br /> Use Only) <br /> BUSINESS NAME(Scone n FAcmxry NAME or DBA-Doing Business As) 3. <br /> SvPeR sTor� 4� of �Ia��fc . <br /> BUSINESS SITE ADDRESS T 103. CITY tat• <br /> . 1V - MA1 N <br /> qi o 15-r * M,A�-+v JF CA <br /> FACILITY TYPE gr1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 405. <br /> El 3.FARM 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes 9090 <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407• PHONE 408• <br /> i S C.r �DoZ-4 EN" R l�lc$ 205 239- u141. <br /> MAILING ADDRESS 409• <br /> P D- 2)0) -7 D Z <br /> CITY A N I Lu ato. STATE 411. ZIP CODE 3 3 atz. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> N DF-r Dt Svc r� � F-i <br /> NAjZ - ( 201) <br /> MAILING ADDRESS 428-3 <br /> Zc10 �. M A�n� <br /> CITY 428-4 STATE 428-5 1 ZIP CODE 428.6 <br /> NMAtrfi�A I Ctk `T's L <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> G AROOZ A (2 opt) 2'-i->Ct -414 i <br /> MAILING ADDRESS 416. <br /> 1132 N. fliglrNI sr <br /> CITY 41 STAAr E 418. ZIP_ OD 33 419. <br /> IMANTELA <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420• <br /> [1 �7.FEDERAL AGENCY .5.isNON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 101 -1, 114 16 1 q I D I Call the State Board of Equalization,Fuel Tax Division,if there are questions. 42F <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER [14.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 fiance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424• 1 PHONE 425• <br /> 0 a®5 z 9 47_ 4/LI <br /> APPLICANT NAME(print) 426- APPLICANT TITLE 427 <br /> M.Af,10ECP- C)A4 ' ttl's'rtecs 01v,t'16-k <br /> UPCF UST-A Rev.(12/2007) <br />