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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 400. <br /> (Check one item only) �1� ❑ 7.PERMANENT FACILITY CLOSURE <br /> X9RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# I I _ I I I 1 1 <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as FACILFFY NAME or DBA-Doing Business As) 3- <br /> 5'o P e r?- <br /> SoPe2 ToP C'41 I'QL')oe . <br /> BUSINESS SITE ADDRESS 103. CITY too. <br /> NAA-"TG-C,^ CA <br /> FACILITY TYPE MOTOR VEHICLE FUELING 403. 405. <br /> ❑ 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ❑No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> MAILING ADDRESS 409 <br /> It 3 Z IV M 4 I'" S T <br /> CITY 47 STATE 411. <br /> ZIP CODE 412. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. 1 PHONE428-2 <br /> M• r'jDecl� a�,q (209 ) 71S � i 8d <br /> MAILING ADDRESS 428-3 <br /> 2-91 . N ; 1., s r. <br /> CITY428-0 STATE 4za-s <br /> _ ZIP CODE 428-6 <br /> (-AC4pi, <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> MAILING ADDRESS 416 <br /> CITY an. STATE 418. ZIP CODE 419. <br /> M#"TE CA �} X5374. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY MArNON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1Call 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: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER (15.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 compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. 1 PHONE 425 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> UPCFUSARev.(12/2007) ` � 1. <br /> "yt <br /> nNED <br /> � <br /> \V <br />