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E <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK F P x, 2 2, 01 ? <br />OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br />(One form per facility) <br />]r <br />TYPE OF ACTION ❑ 1. NEW PERMIT 0 5. CHANGE OF INFORMATION 0 7. PERMANENT FAG <br />(Check one item only) 3. RENEWAL PERMIT [1 6. TEMPORARY FACILITY CLOSURE 0 9. TRANSFER PERMIT <br />L FACILITY INFORMATION <br />TOTAL NUMBER OF USTs AT FACILITY <br />FACILITY ID <br />IAgency <br />Use Or, <br />F <br />BUSINESS NAME (Same as Facility Name or DBA - Doing Business As) 3. <br />TiqAtfi",1 -acx �Y- (40 09,'� SI -10,P Al <br />BUSINESS SITE ADDRESS 103. <br />CITY 104. <br />hve- <br />ah cr-AA/ <br />FACILITY TYPE'i. MOTOR VEHICLE FUELING C1 2. FUEL DISTRIBUTION 403. <br />Is the facility located on lndiaq�,Reservatjon or 405. <br />❑ 3. FARM El 4. PROCESSOR 0 6. OTHER <br />Trust lands? ❑ 1. Yes No <br />111. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME aoz <br />A499 'Pr yet Ar -S Z-1 C - <br />PHONE aos. <br />MAILING ADDRESS 409. <br />CITY 410. <br />STATE 411• <br />1 ZIP CODE 412. <br />111- TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME [ONE 428-2. <br />W191w AAA11 <br />MAILING ADDRESS 428-3. <br />- q '04e&'Ax1) / 9 <br />CITY 428-4. <br />1 STATE 428-5- 1 <br />ZIP CODE 428-6. <br />cg_ <br />61> <br />�j <br />IV. TANK OWNER INFORMATION <br />TANK OWNER NAME ata. PHONE 415. <br />& 9�?7-_/ <br />MAILING ADDRESS 416. <br />-2-Wfiv <br />CITY r 417. <br />STATE 418. <br />ZIP CODE 419. <br />OWNER TYPE: [1 4. LOCAL AGENCY/DISTRICT 0 5. COUNTY AGENCY ❑ 6. STATE AGENCY 420. <br />El 7. FEDERAL AGENCY 2)K�. NON-GOVERNMENT <br />V. BOARD OF EQUALIZATION!6ST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) HQ 62 r0 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: 0-1�FACILITY OWNER ❑ 4. TANK OPERATOR 423. <br />ffK3. TANK OWNER ❑ 5. FACILITY OPERATOR <br />SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required for Public Agencies Only) 405. <br />V111. APPLICANT SIGNATURE <br />CERTIFICATION: I certify that the information provided herein is true, <br />accurate, and in full compliance with legal requirements. <br />APPLICANT SIGNATURE <br />DATE C1, 12-- 1 424. 1 PHONE 425. <br />q)� m -9 q/ <br />( ) <br />APPLICANT NAME j-prin6- 426. <br />�AoVVjjc- ((� <br />APPLICANT TITLE 427 <br />riA <br />Mckm gy" <br />UPCF UST -A Rev. (12/2007) -1/2 www.unidoes.org <br />