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UNIFIED PROGRAM CONSOLIDATED FOICY-1 J �/ �;r:l <br /> UNDERGROUND STORAGE WANK <br /> E: OPERATING PERMIT APPLICATION�-FACILITY INFORMATION i`^ <br /> (Qnc form per facility) <br /> 400, <br /> TYPE Of ACTION ❑ 1,NEW PERMIT CI 5.CHANGE OF INFORM7TION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Check oneRPAWait) 3.RENEWAL PERMIT © 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I 'AGILIY'YIN . . <br /> i�1�,1�ATi�J►N <br /> (Agency Use 040 <br /> TOTAL NUMBER OF USTs AT FACILITY ana. PACILiTY ID <br /> 3, <br /> BUSINESS NAME(Same as Pacift,Name or DA/1-Doig Business As) <br /> BUSINESS SITE ADDRESS 103. CITY 104, <br /> 403. 05, <br /> FACILITY TYPE r1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRTBLMON Is the facility located on Indian Reservation or <br /> 3.FARM ❑ 4.PROCESSOR 6.OTHER Tnist lands? ❑ T.Yes Z.No <br /> II: okm1t' v OWNEI .INFORMATION: <br /> [/1 <br /> PROPERTY OWNER NAME ao7. PHONE aos. <br /> �vVti AAI �' ' `-'*Z4 ` 0 1 409, <br /> MAILING ADDRESS <br /> CITY 410, STATE 411. ZIPCODE 412, <br /> 'TANK OMA <br /> Tolt INFO <br /> TANK OPERATOR NAME p 423.1. PHONE 428.2. <br /> , •,ri M �-lit C.. ( ) 4 <br /> MAII.TNO ADDRESS 42R.3. <br /> CITY <br /> 428-4, STATE 429-5. ZIP CODE 428-6' <br /> „ <br /> IVTATK,OWNER.MF4MTIt7N <br /> TANK OWNER NAME 414• PHONEp 413. <br /> MAILING ADDRESS 416' <br /> CITY 417. STATE� r✓�d2-- �, 416, zIPCODE 419. <br /> 15s '( <br /> OWNER TYPE.- �j 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY azo. <br /> ❑ 7,FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> ' �+, QU IZA'X'�UN US's,'S�t0"ryE.FEE•. fj <br /> v. A... .. <br /> y., <br /> ObN <br /> 1Y(TK)HQ 44- 'C) Call t11c State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> .. .. -Ali., <br /> 423. <br /> Issue pennit and send legal notifications and mailings to; 1.FACILITY OWNER [714.TANK OPERATOR <br /> [� 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,ST3CTI0N,OR Of <br /> FTCE(Required for Public Agwios Only) 41x. <br /> CERTIFICATION: I certify that the information provided herein is trp accurate a d in full compliance with legal re virelRments.—�= <br /> APPLIC ?VT SIGN DATE 424, 1 PHONE <br /> © , X 9 til ff- <br /> APPLICANT NAME(print) 42Ci, APPLICANT' lT 427 <br /> �^ <br /> UPCF UST-A Rev.(1212007)-1/2 www.unidoes.or lt3 <br />