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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK l <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 <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# <br /> 7 (Agency Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. <br /> U P, URN 0 :1N (•_ <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> `.l H U C c7v L_-AT R O'tl <br /> FACILITY TYPE 1.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 nNo <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408. <br /> LJ <br /> MAILING ADDRESS 409. <br /> 0 0 2 Q.al Co C K <br /> CITY 410. STATE all. ZIP CODE 412. <br /> s NV qci ,� � <br /> III. TANK OPERATOR INFORMATION <br /> TANK OP BATOR NAME 428-1. 1 PHONE 428-2 <br /> R `r Cwt&-) C-0 <br /> MAILING ADDRESS 428-3 <br /> 1�0 <br /> CITY 428-4 STATE 428-5 1 ZIP CODE 428-e <br /> 2 v 6 'l 6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> MAILING ADDRES ale. <br /> 2C, c( ►' CJS >2Y9 f Lf6 <br /> CITY ay. STATE 418. ZIP CODE 419. <br /> CITY 7 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 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: [11.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 compliance with legal requirements. <br /> APPLICANT SIGNATUR_E DATE 424. PHONE 425. <br /> Z5 GAJ I I <br /> APPLICANT NAME(print) 426. APPLICANT TITL 427 <br /> UPCF UST-A Rev.(12/2007) <br />