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Quick STOP Mart 2098254569 P.3�-( <br /> • 44 IliollZ <br /> UNIFIED PROGRAM CONSOLIDATED FORM 1101 <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form per faeiIAy) <br /> TYFE OF ACTION ❑ 1.NE W PERMIT <br /> (Check S.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOS RtE a0R' <br /> `0111 ❑ 3.RENEWAL PERMIT ❑ 6.'TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERM <br /> L FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 4a4' FACILITY ID 8 _ 4 <br /> (Agency U-0*) <br /> BUSINESS NAME(SaaS as pht:il.r[Y NAM«Dew_txmg 6usinas A:)\ <br /> 3, <br /> BUSINESS SITE ADDRESS t114 <br /> /,76 ` 1l 103. CITY <br /> FACILITY TYPE , MA <br /> ❑ 1.MOTOR VEHICLE FUELING ErZ.FUEL DISTRIBUTION ' is the facility located oon[avian ResFrvation or 405. <br /> 3.FAR11i 4.PROCESSOR 116.OTNER I Trust lands? ©Yes Mo <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTYOWNEItNAME ���Eftj (Z $ <br /> MAILING ADDRESS <br /> W � 499. <br /> CITY <br /> �Q� 4ra. STATE 411 ZIPCOI)E 412. <br /> i.-T9 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428 1- M <br /> ONE 423-2 <br /> MAII.INGADDRESS a"� ) . a5 <br /> o / 43 <br /> CITY <br /> u ° STATE +�•3 ZIP CODE 42" <br /> �(f S <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNERNAME <br /> 474. p}IOptE 415. <br /> rtr+ oC, <br /> 1NAIL DRESS <br /> 415. <br /> CITY 4n• STATE 418 1ZIP C <br /> OWNER TYPE: ❑ 4.LOCAL Y/DISTRICT ❑ S.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> j� 7.FEDERAL.AGENCX 018.NON-GOVERNMENT <br /> Y. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> T (T �11Q Ca11 the Slate Board OfEqualizatiou,Fuel Tax Division,ifthem are42L <br /> gtltstions. <br /> VI.PERMIT HOLDER INFORMATION <br /> lssue permit and send tegal o0tifrcaWms and mailings to: l.FACILITY OWNER 473 <br /> ❑ 4.TAMC OPERATOR <br /> 6?s.TANK OWNER 0 5,FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required Far Public Agencies Only) 4% <br /> VIL APPLICANT SIGNATURE <br /> CERTiFICATIONs l oertw that the imbruatd-eruvided herein 15 tree,acceratt,and in toll corn itlact with 1 <br /> APPLICANT SIGuitYmt 1>ts. <br /> NATURE DATE 424. <br /> PHONE 4zs. <br /> �APF�LJCANTME(print) "?0 17 des -qs� <br /> aP zc ) <br /> 42 <br /> �Gtn <br /> UPCF UST-A Rev.(inion <br />