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�L C <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK 2-) �1? <br /> / <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION kk1p/,meq <br /> (One form 1ty)I <br /> TYPE OF ACTION ❑ 1.NEW PERMIT [15.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE ' <br /> (Check One hem only) �aj.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L FACH.ITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY FACILITY ID# I _ _ 1' <br /> 5 (Agency Use Only) <br /> BUSINESS NAME(same as FAcm=NAME or DBA-Doing B.&.At) 3• <br /> BUSINESS SITE ADDRESS 103• CITY .11 104. <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 40• <br /> 3.FARM 4.PROCESSOR 6.OTHER Trust lands? ❑Yes O-No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407• 1 PHONE 408. <br /> � 1 i 1 KcL - <br /> MAILING ADDRFec 409. <br /> CITY 410. STATE 411• 1 ZIP CODE 411 <br /> 2-0 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> MAILING ADDRESS 428-3 <br /> CITY 428.4 I STATE 429-5 ZIP CODE 42M <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME ,y 414. PHONE 415. <br /> MAILING ADDRESS <br /> CITY l' 417. 1 STA 418. ZIP CODE n 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY )5�18.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGEYEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 10 14 74 �j 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: 04.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER [15.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VH.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the info madon provided herein h trae,accurate,and in full compHance with IeZW requirements. <br /> APPLICANT ADATE 424. PHONE S 425. <br /> APPLICANT NAME(print) 426. APPLICANT TITLE an <br /> �,t->?i-} 1✓��,i (7-D 4� <br /> UPCF UST-A Rev.(12/2007) K <br /> V,.. <br /> t ��• <br />