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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION- FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION L 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# <br /> J�x (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 <br /> 5440tm C ole Abe <br /> BUSINESS SITE ADDRESS1190 Oww&eC LN 103. CIT1 �i 104 <br /> FACILITY TYPE C31.MOTOR VEHICLE FUELING El 2. <br /> j�r��2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR go 6.OTHER Trust lands? ❑ 1.Yes ❑ 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> MAILING ADDRESS 409' <br /> CITY 410. 1 STATE 411. ZIP CODE 412. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. /PHONE 428-2. <br /> l <br /> MAILING ADDRESS 428-3' <br /> CITY 4284. 1 STATE 428-5. ZIP CODE 428-5. <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. /PHONE 415. <br /> l <br /> MAILING ADDRESS 415' <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(TK)HQ 44_ 1 1 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) 405' <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal re uirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 425. <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />