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C6)i <br /> UNIFIED PROGRAM CO EII <br /> UNDERGROUNDS <br /> OPERATING PERMIT APPLICATI N-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION C11.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE aoo. <br /> (Check one item only) D'3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSU .1C�P.IC31e q ��'F�PPERMIT <br /> I. FACILITY INFO RMA FRONME u AL <br /> c <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# _ 1-7 <br /> (Agency Use Only) <br /> BUSINES NAME ame wfACILIJY NAME or DB -Doing Burin s As) 3. <br /> BUSINESS SITE ADDS 103. CITY 104. <br /> C <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING E] 2.FUEL DISTRIBUTION 403 Is the facility located on Indian eservation or aos. <br /> [13.FARM ❑ 4.PROCESSOR A <br /> 6.OTHER Trust lands? ElYes NO <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> �6 386'370 <br /> MAILING ADDRE S 409. <br /> Z <br /> CIT Y `um C�� 410. STATE alt. ZIP COT��� � atz. <br /> ` <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHO428-2 <br /> ' �- c NE( l >38�-X767 <br /> MAILING ADDRESS p goo^^�� 428-3 <br /> L �" <br /> CITY � r 428'4 7STATE 428-5 ZIP CODE 428'6 <br /> �ur�en-{1,uC& ✓ � <br /> IV. TANK OWNER INFORMATION <br /> TANK OWN R NAME ala. PHONE 415. <br /> r�ncr-� c (q 1 o &8 6-37 0 <br /> MAILING ADDRESS 416. <br /> 2- <br /> CITY 417. STATE418. ZIP COD J � ( 419. <br /> Sac v C17S(er <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 /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICA ON: I ckrtifythat the information provided herein is true accurate and in full compliance with legal requirements. <br /> APPLICANT SI AE�� DATEI�� I 424, PH E ��.3r61425 <br /> APPLICANT A (print) 426. APPLICANT TIT ( qi6 7 ,427 <br /> sTtkk <br /> a o �n the <br /> UPCF UST-A Rev.(12/2007) <br />