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A <br />C <br />.l1 �► 2, <br />QjT1 obc <br />011111 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br />(One farm per facility) <br />"TYPE OF AC TION� 1 NEW PERMIT ❑ S. CIIANGE OF INFORMATION [37. PERMANENT FACILITY CLOSURE a0° <br />t0WA ane nem tMntyt 0 3. RENEWAL PERMIT ❑ 6. TD4PORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT <br />1. FACILITY INFORMATION <br />TOTAL NUMBER OF USTs AT FACILITY � �° <br />FACILITY iD Y <br />� <br />J� <br />s <br />T <br />,(� <br />iC <br />V <br />� <br />� <br />j„ <br />L.� <br />Lf <br />? <br />t <br />(Agency Lae lhrh'i <br />j <br />(� <br />v <br />J <br />BUSINESS NAME (UTK.�-,.AMNAsMt MA -Don$ + unn+w,'r s <br />BUSSUvES–S} SITEIAD R�.SS ►a3. CITY Iw <br />}:A(:ILITY TYPE Pi. MOTOR VEHIC .E FLELING ❑ 2. FUEL DISTRIBUTION as' is the facility located on lodtaa Reservation cw <br />Trust latuis7 ❑ Yes ❑ No <br />3, FARM 0 4. PROCESSOR 0 6. OTHER <br />H. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NA'NtEa?• PHONE � <br />MAILING ADDRESS <br />CITY <br />STATE si.ti <br />4t2.sia, <br />E <br />q,-5sG5V <br />111. TANK OPERATOR INFORMATION <br />_ <br />TANK ( PEF-k-t OR IN,"'a _ C&L Pi ON!? 421.2 <br />o <br />AIAIi IN ADDRESS <br />CITY 42ts <br />STATE 421' <br />ZIP CODE 421b <br />IV, TANK OWNER INFORMATION <br />TANK O%kNER NAM .Ira. <br />PHONE % <br />ilz <br />MAILINGADDRE.r$S _ ars <br />r-- _V <br />CITY 417, <br />STATE ata. <br />ZIPCODE 410• <br />OWNER TYPE: ❑ 4. LOCAL AGENCYANSTRICT ❑ 5. COUNTY AGENCY ❑ 6. STATE AGENCY 420, <br />Q 7. FEDERAL AGENCY 8, NON-GOVERNMENT <br />V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) HQ 44_ Cao Ute Slate Board of Egttolizatim% Fuel Tax Division, if thm are gttestiotta. ser, <br />V1. PERMIT HOLDER INFORMATION <br />Esme permit and send legal notificatiom =4 ((tailings to: ❑ 1. FACILITY OWNER 4. TANK OPERATOR azt <br />3. TANK OWNER ❑ S. FACILITY OPERATOR <br />4%, <br />SUPERVISOR OF DIVISION. SECTION. OR OFFICE (Rogvired For Public Ades Onty) <br />VII. APPLICANT SIGNATURE <br />CERTIFICATION: I cert0ly that the laormadott provided itereMo Is <br />nenirat aad is (all tots vw4th tdraneats. <br />DATE 41a PHONE <br />! o ► I� h' - 56-5201D <br />5700 <br />APPLICANT SIGNATURE <br />APPLICANT NAME (print) 428 <br />APPLICANT TRLE <br />UPCF UST -A Rev. (I2RA47) <br />