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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 C] 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION [17.PERMANENT FACILITY CLOSURE 400 <br /> (Check one item only) 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I� .FA Y INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID#A _ _ �+ Q 1. <br /> 1 (Agency Use Only) O 4 � J S ` <br /> BUSINESS NAME(Same as FACILITY NAME m DBA-Doing Business As) 3. <br /> DAME-R-oN N-as P(-+A-L- c o Al <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> t a 'a s-h'te,- T -rok) q5 03 <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR 6.OTHER Trust lands? ❑Yes )<No <br /> i <br /> iHT Y O'' NER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 4087 <br /> " Q t1S ,` W k6c6'ocb O aoq M - 5 c <br /> MAILING ADDRESS 5409. <br /> Same Q ye- <br /> CITY 41°. STATE 411. ZIP CODE 412. <br /> IHR:OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> S0 M G Aj3ave <br /> MAILING ADDRESS 423'3 <br /> CITY 4287 STATE 423-5 ZIP CODE 428-6 <br /> iY 'TAN: 'OWNER INFORMATION <br /> TANK OWNER NAME ala. PHONE 415. <br /> SWIE A5 <br /> MAILING ADDRESS 416. <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY ago. <br /> ❑ 7.FEDERAL AGENCY %8.NON-GOVERNMENT <br /> V. BOARD OF EQ3ALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 10 1 a I Lj I L41 I I 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 /> VI .APPLICANT SIGNATURE <br /> /ICMTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APP ICANT SIGNAT RE DATE 4247 PHONE .,,;`; 425. <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> O <br /> tax\ <br /> UPCF UST-A Rev.(12/2007) ""' <br />