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60rall <br /> �h` UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> n O V 0 7 SKRATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE( C�' INWKEW PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE aoo. <br /> (Check one iFMWW9(W EWAL PERMIT <br /> „. ❑ 6.TEMPORARY FACILITY CLOSURETIN <br /> S.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# _ H C� I <br /> (Agency Use Only) ` <br /> BUSINESS NAME(Same as FACILrFY NANNE or DBA-Doing Business As) 3_ <br /> '24 HR CNS -,?- r^A R+ <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> DI S V'--'L c> bt 6,foe.l;l^TA b oc. -tov\ <br /> FACILITY TYPE 0-,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 IgNo <br /> H. PROPERTY OWNERINFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> M b kA4M <br /> MAILING ADDRESS 409. <br /> 0�� <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> � Ise- Oq 11 GOO a <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> i,-, 1E V MV�'i - - J x-1'9 <br /> MAILING ADDRESS q 5L1 _ 27 09 428-3 <br /> 174q . C GA lt <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> C� 952-64, <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> MAILING ADDRESS 416. <br /> 0 c el! <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY EK.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 TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> j If VII.APPLICANT SIGNATURE <br /> CERTIFI ION.#,,,tify that the information provided herein is true,accurate,and in full com liance with legal re uirements. <br /> A <br /> APPL IG A DATE 424. PHONE 425. <br /> ► 1 7 - 1 ( 2_") <br /> 2©4 1 5q Z7d <br /> APPLICANT NAME(print) �J 426. APPLICANT TITLE 427 <br /> I�RP,"F P'► , � 31 Dom-i I.� <br /> UPCF UST-A Rev.(12/2007) ¢ -; <br /> ' 3 h <br />