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3 Z vq AAu <br /> UNIFIED PROGRAM CONSOLIDATED FORM At IN In p� <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <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 T FACILITY 404' FACILITY ID# _ _ 1' <br /> (Agency Use Only) <br /> BUSINESS NAME(s.as FACILITY NAME or DBA-Doing Business As) 3 <br /> BUSINESS SITE ADD SS 103. CITY 104• <br /> FACILITY TYPE 1.MOTOR VEHICLE FfJELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 405. <br /> 3.FARM 0 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes XNo <br /> PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME <br /> „ 407• PHONE 408• <br /> MAILING ADDRESS 409• <br /> ''7// �� 5 <br /> CITY 410• STATE 411• ZIP CODE 412. <br /> eze-71;'IJ 624 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1• 1 <br /> /PHONE r� 428-2 <br /> MAILING ADDRESS 428-3 <br /> ZW rl <br /> CITY 428-4 1 STATE 428-5 1 ZIPCODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414• PHONE �j 415. <br /> �c ©19� 142 ��Li�� <br /> MAILING ADDRESS 416. <br /> C7 <br /> CITY 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- 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 /> ❑ 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 that theVorm4don provided herein is true,accurate,and in full compliance with legal requirements. <br /> ADPL ANT SI NATURE DATE 424• PHONE 425• <br /> 0 - 3 <br /> APPLICANT N t) 426• APPLICANT TITLE 427 <br /> UPCF UST-A Rev.(12/2007) <br />