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AdlILL <br /> IED PROGRAM CONSOLIDATED FOIW <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility)E: <br /> TYPE OF ACTION C] 1.NEW PERMIT El5.CHANGE OF INFORMATION El7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION JT� <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3' <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> FACILITY TYPE -E� 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION ao3. Is the facility located on Indian Reservation or acs. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> MAILING ADDRESS 409. <br /> 3 a40 t���-�� �� Gv-14 <br /> CITY 410. 1 STATE411. ZIP CODE 412. <br /> ��. C A q 5 3 z0 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> CA A LN No\t 5 . Lk--r L_t ( 20`1) S'3 C's g <br /> MAILING ADDRESS 428-3 <br /> 3 140 Nt,(L-'Cry � �J <br /> CITY 428-4 1 STA428-s ZIP CODE 428-6 <br /> TE <br /> a- C A 53� <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> 4167 <br /> MAILING,kDDRESS <br /> CITY �_ 417. 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- 1 (L) I LA- (7 -S (Q 10 r 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: g 1.FACILITY OWNER C] 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION:-.XteftT-'that a infoyination provided herein is true accurate,and in full compliance with legal requirements. <br /> APPLICANT SJGNATIVRE - DATE 424. PHONE 425. <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> CAAp,LAN !,i` Q o t-3 <br /> UPCF UST-A Rev.(12/2007) <br />