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> <br />AD k/6 -7 L <br />UNIFIED PROGRAM CONSOLIDATED FORM 7 <br />UNDERGROUND STORAGE TANK <br />E: <br />OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br />(One form per facility) <br />TYPE OF ACTION 01. NEW PERMIT ❑ 5. CHANGE OF INFORMATION [1 7. PERMANENT FACILITY CLOSURE 400. <br />(Check one item only) ❑ 3. RENEWAL PERMIT ❑ 6. TEMPORARY FACILITY CLOSURE 0 9. TRANSFER PERMIT <br />I. FACILITY INFORMATION <br />TOTAL NUMBER OF USTs AT FACILITY 404. <br />3 <br />1 FACILITY ID #All <br />1 <br />1 <br />7 <br />(Agency Use Only) <br />6,7! <br />BUSINESS NAME (same as FAcmxrY NAME or DBA - Doing Business As)3. <br />F/ R F T C VI�FA CAf- i -r -'E -,V IL 1) SA PARkwob,b q4l�-f 9-- F& -b -b <br />BUSINESS SITE ADDRESS103 - <br />612- w m ft La" e- <br />CITY l04 <br />-ro ck-To c ao <br />FACILITY TYPE 19 1. MOTOR VEHICLE FUELING El 2. FUEL DISTRIBUTION 403. <br />Is mthefacility located on Indian Reservation or 405. <br />E] 3. FARM 4. PROCESSOR [3 6. OTHER <br />Trust lands? [] Yes No <br />H. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME40" <br />ri R 3 T 04 <br />PHONE 401, <br />C '9) 9 1 <br />_) L <br />MAILING ADDRESS 409. <br />161a W, 1-k M M 5A LAtl 5, <br />CITY 410. <br />STATE CA all. <br />ZIP CODE 412. <br />111. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 429-1.1 <br />PHONE 429-2 <br />FIRST OIL- COPP <br />(aur) 95-1-91op <br />MAILING ADDRESS 428-3 <br />--[SITWAT�E <br />CITY 4284 <br />428-5 1 <br />CA <br />ZIP CODE 42M <br />LA 7;:>? <br />IV. TANK OWNER INFORMATION <br />TANK OWNER NAME 414. 1 <br />r 19 O(L_ C_6 IQ <br />'ST FV <br />PHONE 415. <br />(aoj) Is <br />MAILING ADDRESS 416. <br />614 W, No M M 4--k- Lt(t4 C- <br />cny 417. 1 <br />9 -To C�---Ta ^-f <br />STATE 411* <br />C'VA_ <br />ZIP 419. <br />I S- 0? (1 C/ <br />OWNER TYPE: [1 4. LOCAL AGENCY/DISTRICT ❑ 5. COUNTY AGENCY [1 6. STATE AGENCY 420. <br />0 7. FEDERAL AGENCY 8. NON-GOVERNMENT <br />V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />Ty CIK) H2 44- 1014 1614 10 14 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 [1 4. TANK OPERATOR 423 <br />F-1 3. TANK OWNER ❑ 5. FACILITY OPERATOR <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 compu with I I airements. <br />fiance M� reg <br />APPLICANT SIGNATURE <br />1_ <br />DATE 424• <br />---- <br />425.ig <br />PHONE 425. <br />APPLICANT NAME (p 42 6. <br />rAimiz,TPAL TLk,,C,, ej <br />= 27 <br />APPLICANT E 4 <br />CFO <br />kA <br />UPCF UST -A Rev. (12/2007) <br />