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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 C!f 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> L'FACILITY INFORMATION 101 <br /> (3101 -1012-1 <br /> rr�TOTAL NUMBER OF USTs AT FACILITY 40f (FACILITY ID# <br /> Agency Use Only) { ` V L 11-7 <br /> BUSINESS NAME(sane as FACILR'1 NAME or DBA-Doing Bminess As) 3. <br /> L LNvFSTM TI' Lc-C . i38A4i\ t0 1146SS1)A1� <br /> BUSINESS SITE ADDRESS 103- <br /> y vlf M o ST p A tr F R L,4Ty,Qt P' CA CITY � A7"H/��,v 1�4. <br /> FACILITY TYPE A 1.MOTOR VEHICLE FUELING [12.FUEL DISTRIBUTION 403. Is the facility located on Indi n Reservation or ' <br /> 3.FARM 4.PROCESSOR 6.OTHER Trust lands? ❑Yes No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME au 417. PHONE 409• <br /> Ri-T L- � , d a 2!1 7 `2 77 <br /> MAILING ADDRESS 409. <br /> y Cwt 6.76 & <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> �SFvj LLE <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 429-7PHONRE 429-2 <br /> U S�' i, 67A-C j IV C ' ) <br /> MAILING ADDRESS 429-3 <br /> 11 t/ B O SS' Z) <br /> crrY <br /> 429.4 STATE 428.5 ZIP CODE 428.6 <br /> L >`1 � 3 3 r, <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> MO-CIDA i.F_ jN J lr M '7S LLC, 7jQ 6 <br /> MAILING ADDRESS 416• <br /> y L2 f7 �, /I/cc- <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Vic Le ,� 9 � , P <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(TIC)HQ 44- JCJCall 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 ❑ 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 informadon provided herein Is true accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424- PH NE 425 <br /> �Zl <br /> APP CANT NAME(print) 426. APPLICANT TIT11p 4 . <br /> UPCF UST-A Rev.(1712007) <br />