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it # <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 Qf 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 4D4. FACILITY ID# i / I' <br /> �1 A V11 LS 1 1(Agency Use Only) � 1010 <br /> L I d C� <br /> BUSINESS NAME(Same as FACU rrY NAME or DBA-Doing Business As) 3- <br /> V-a CSL S'F`:�) .4 <br /> BUSINESS SITE ADDRESS 103. CITY104. <br /> D ) Ve S C C r' StD <br /> c-i 2\S' " . CICtMA <br /> C - Cvlsl LS7 <br /> FACILITY TYPE Er1.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 ,®'No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 01,Wi 11 '1 Se�aY v� <br /> Li JE) <br /> - _Al0$ <br /> MAILING ADDRESS 409• <br /> 2-6-7 a Z D �A 11 S vee <br /> CITY 410- 1 STATE 411- ZIP CODE 412. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME LA5 H 111'r -T 428-1. PHONE Z_0q 428.2 <br /> Seo I"3 MCA-6k� 1 C-, ( - 8�-� <br /> MAILING ADDRESS 3 p Q )1 V eV-'- s C[C+V-yl 428-3 <br /> CITY L 42" STATE azs s ZIP CODE 428-6 <br /> f= ' ..5�-s✓C <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414• PHONE 415. <br /> 3to I' (S 10 ) S- I - 8 Sz-b <br /> MAILING ADDRESS 416. <br /> qY1 r- l-�S <br /> CITY � � �e m O� � 417. STAT /orata. ZIP CODE 419. <br /> ^ !8� <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(K)HQ 44- o ` G 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: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> JP 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! Wth 1 al r uirements. <br /> APPLICANT SIGNATURE i t 4 DATE "� 220 I 424. pgp 425. <br /> W� 20 I u -�?3 <br /> APPLICANT NAME(print) u,&kA via� 1 426. APPLICANT TITLE n 427 <br /> UPCF UST-A Rev.(12/2007) <br />