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ft <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK �l <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION t t <br /> (One fordf per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT -M 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (ChB`OnC item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L-FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404, FACILITY ID# I 1' <br /> l- (Agency Use Only) - - <br /> BUSINESS NAME(Some w FAcam NAME or DBA-Doing B�eh=As) 3. <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> m1 C> ( S E-L- S T 6k,al til C/&a ati' <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION �3' Is the facility located on Indian Reservation or 405' <br /> 3.FARM 4.PROCESSOR [16.OTHER Trust lands? ❑Yes No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4W. PHONE 408. <br /> MAILING ADDRESS 409. <br /> lC1(Jl S • Pt- P 0r/�Q0 2--'o C' <br /> CITY 410. STATE 411. ZIP CODE ail. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4281• PHONE 428-2 <br /> Slt�? fitd ae ( ) <br /> MAILING ADDRESS 428 3 <br /> CITY 428-4 STATE 428.5 1 ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> MAILING ADDRESS 4167 <br /> Sf-�v✓1� A-� /�!5 c vE <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420• <br /> ❑ 7.FEDERAL AGENCY 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGEFEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- d / Call the State Board of Equalization,Fuel Tax Division,if there aro questions. 421. <br /> VI.PERMU HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: .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) 4N• <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I cern that the information provided herein Is trn accurate,and in full com lisn4ie with lexall requirements. <br /> c. ,AP ICANfT SIGNATURE DATE ata. PHONE au. <br /> qt/f <br /> APPLICANT NAME(print) a 426• APPLICANT TTfLE IVIMI tUll 427 <br /> UPCF UST-A Rev.(17/2007) <br /> Pill cloda <br />