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a � ?lZy lei <br /> N <br /> UNIFIED PROGRAM CONSOLIDATED FORM `/e 71, 710 <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> E "- "- /--"�V- � rtp 'lily) <br /> TYPE OF ACTION X 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.P 4W' <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION JUL 2 2 2009 <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# VI O N1 E 1H 1 <br /> (Agency Use Only) T4cL <br /> BU$INES$ AME(Sero as FACI[M or DBA-Dojpgpisiness ) 0 3' <br /> BUSINESSSITEADDRESS 103. CITY, 104. <br /> )On I L&tteM 403 <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION ' Is the facility located on Reservation or 40. <br /> 3.FARM 4.PROCESSOR 6.OTHER Trust lands? ❑Yes No <br /> II PROPERTY OWNER INFORMATION <br /> PROP OWNER NAME soy PHONE 4W. <br /> rb (IM12 ObANI.- L `� ,09. <br /> MAILING ADDRESS <br /> CITY ato. STATE 4171 CODE a12. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OP BATOR NAME 428 1- PHONE azs 2 <br /> 11 <br /> 428.3 <br /> MAILING ADDRESS <br /> riLOGLA <br /> CITY 428.4 STATE 423-5 ZIP DE 428.6 <br /> Cl <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME414. PHONE 415. <br /> "Imr h► l�o�. <br /> 416. <br /> MAIL ADDRESS <br /> �!) an. STA ata. ZIP f at9. <br /> CITY � Com`/ <br /> OWNER TYPE: A 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EOUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- <br /> Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> 423 <br /> Issue permit and send legal notifications and mailings to: ❑ I.FACILITY OWNER [34.TANK OPERATOR <br /> je 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 cerdft that the information provided herein is true,accurate,and in full complian <br /> aznce PH requirements. 425. <br /> APPLICANT SIGNATURE DATE <br /> D'la"►1 5 . -7 LQ o q acs 9 J <br /> APPLIC NAME(print) <br /> 1 426. APPLIC TITLE 4n <br /> UPCF UST-A Rev.(12/2007) <br /> a <br />