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4 <br /> &/ <br /> UNIFIED PROGRAM CONSOLIDATED FORM 1 <br /> UNDERGROUND STORAGE TANK :9 11 �! <br /> E.OPERATING PERMIT APPLICATION- FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT C35.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 4 FACILITY ID# // �/ <br /> x '-D4 (Agency Use Only) Z. _l 57 <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> x i12 A�- O S£Rv C£ <br /> BUSINESS SITE ADDRESS 103. CITY 1oa. <br /> >` iff AJ -FV A 81VA SX C a Cl S3 7 T 'A �- <br /> FACILITY TYPE L MOTOR VEHICLE FUELING E] 2.FUEL DISTRIBUTION 403 RIs the facility located on Indian Reservation or 4os. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes ❑ 2.No <br /> �o II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE aos. <br /> S/AVC7Mtn RT ) S7" -7-110 <br /> MAILING ADDRESS ao9. <br /> �D 12) K4 09IM10 <br /> CITY 410. 1 STATE 411. ZIP CODE 412. <br /> q5�5 <br /> X III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2. <br /> MAILING ADDRESS 428-3. <br /> 3.75_ &f 1zA 6 rid <br /> CITY 428-4. STATE 428-5. ZIP CODE 428-6. <br /> OSO76 <br /> `, IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME ata. PHONE 415. <br /> 416. <br /> MAILING ADDRESS <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <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(TK)HQ 44- 11 4, 1f Z 1112J 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 /> 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 thVthe Wformation provided herein is true accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE 00& DATE Z 424 PHONE azs. <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> UPCF UST-A Rev.(12/2007)-1/2 www.maidoes.org <br /> I <br />