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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION- FACILITY INFORMATIO <br /> (One form per facility) <br /> TYPE OF ACTION 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <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# t. <br /> (Agency Use Only) I <br /> IA <br /> _ 13;1 `' <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> BUSIN SS SITE ADD SS � 103 CIT 104. <br /> `Zr 4Q-o t---t�� <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Iqdjpn Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR 6.OTHER Q L, Gr'(xTrust lands? ❑ 1.Yes 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PR ERTY OWNER NAME 407. 1 PHONE 408. <br /> 900 X 404C) <br /> MAILING ADDRESS <br /> 409. <br /> CITY 410. STATE 41 L ZIP CODE 412• <br /> � cis <br /> 111. TANK TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME I) ",-1. PHONE 428-2. <br /> MAILING ADDRESS 428-3. <br /> CITY 428.4 1 STATE 428-5• 1 ZIP CODE 428-6. <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> MAILING ADDRESS 416. <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(TYQ HQ 44- 0 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: ----E]-+.FACILITY OWNER ❑ 4.TANK OPERATOR 423. <br /> ❑ 3.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 thadke infopfiation provided herein is accurate and in full compliance with legal requirements. <br /> APPLICANT SIGN DATE 424. PHONE 425• <br /> cio, qck) <br /> AP ICANT-NAME ) 426. APPLCIfANT�TITLE a 427 <br /> L44q L Q 5 C- L-- 1 rfs-- <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />