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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILI'T'Y INF I®� <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.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 /> (Agency Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME w DBA-Doing Business As) 3. <br /> MOSS OaA ; Qawef <br /> BUSINESS SITE ADDRESS 101 CITY 104. <br /> (vSS W . a 5 + S'TOC-kToQ <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 4°3. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR 6.OTHER Trust lands? ❑Yes 5P No <br /> H. PROPE TY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Cass 08A ku.P ;tper po9 94 -®a® <br /> MAILING ADDRESS 409. <br /> (P 6S ST <br /> CITY 410. 1 STATE 411. ZIP CODE 412 <br /> s ta�kzo� Ca , ` 520 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME n 4'-5-1 PHONE 4'-S-'- <br /> SA+Mt S Pro ,-'r <br /> MAILING ADDRESS 428-3 <br /> CITY 428-4STATE 4285 ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> S-A m✓ AS i�r 'TV O 081P <br /> MAILING ADDRESS 416. <br /> CITY 411 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 Cb 1 .3131 ( 1 C I Call the State Board of Equalization,Fuel Tax Division,ifthere are questions. 431. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 1.FACILITY OWNER ❑ 4.TANK OPERATOR 433 <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: I certify that the information provided herein is true,accurate,and in full compliance with legal reairements. <br /> APPLIC IGNATURE DATE 424, PHOS 425, <br /> Apriucb&r NAME(prinV 426 APPLICANT TITLE 4'7 <br /> LW F UST-A Rev.(12/2007) <br /> 4, <br />