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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 E] 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE aoo. <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' FACILITY ID# _ _ 1 <br /> (Agency Use Only) <br /> BU INE$ 3. <br /> NAME(Same as FACILUY NA or DBA- ing Business As) <br /> � � t <br /> BUSINESS SITE ADDRESS � 103 CITY 104. <br /> poo `(V o � Cg J <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING 2.FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or aos. <br /> 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER <br /> Trust lands? []Yes ❑No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME ,,, uU�(v{l A 407. PHONE � �� aoa. <br /> CU1' r �a C,1 oxj <br /> MAILING ADDRESS 409. <br /> 00,0 5 kwav% <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> 40C'16� CPC g5a0 (o <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. <br /> • PHONE 428-2 <br /> fIo ( aol ) 413yQ � Q C u <br /> MAILING A DRESS 828-3 <br /> 2.0m S 'meson � . <br /> CITY 428-4 STATE ata-sZIP CODE 428-6 <br /> 5 hoc.64 V1 G� 5 52 0 <br /> IV. TANK OWNER INFORMATION <br /> TANK ER NAME ala. PHONE 415. <br /> rwk1'o•. ( 2 09 ) WS-3M . <br /> MAILING A DRESS / 416. <br /> CITY a1z STATE a1s. ZIP CODE 419. <br /> 5&C"rl CSF 4', -,of <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> K7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 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 /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal re uirements. - <br /> AP C N DATE 424. 1 PHONE 425. �.­000 <br /> • oCT Z L o o 1 <br /> ICANT NAME( ri ) 426. APPLICANT TITLE 427 %' . <br /> UPCF UST-A Rev.(12/2007) Is <br />