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1 0 0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <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) d 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# _ _ l <br /> (Agency Use Only) fi 0i 0 p p C <br /> BUSINESS NAME(Ssmea5lFACU"T orDBA-Doin BusixssAs) <br /> 3• <br /> i1 0.T �JL <br /> BUSINESS SITE RESS 103. <br /> CIF, � 104. <br /> FACILITY TYPE R 1.MOTOR VEHICLE FUELING Elc <br /> 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 405. <br /> 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ❑No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407.• PHONE 408• <br /> / <br /> 1. <br /> MAILING ADDRESS 409• <br /> CITY 410• 1 STATE 411. 1 ZIP CODE f 412. <br /> IIL TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1• PHONE jb 428-2 <br /> c <br /> MAILING ADDRESS t 428-3 <br /> o- HUN 1 + <br /> CITY STATE a28-5 ZIP CODE 428 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> MAILING ADDRESS 416. <br /> V.2 w. q P� <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Sfib:l(c1b�' Cf j )-G �- <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY Q(8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 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: [2"1.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) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIF ATION: I certify that the information provided herein is true accurate and in full com fiance with legal requirements. <br /> APPLI SI ATU DATE 424• PHONE 425. <br /> z� <br /> APPL (print) 4'-6• APPLICANT TITLE 427 <br /> �6J <br /> UPCF UST-A Rev.(12/2007) F E B 0 2 2011 19 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br />