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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 ❑ S.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one hent only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# _ _ / 1. <br /> (Agency Use Only) 7i 7 <br /> USINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> '-"�Atp SS H C P m cao <br /> BUSINESS SITE ADDRESS 103. CITY 104 <br /> CZCZ-17 f\j q Y20 <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING El 2.FUEL DISTRIBUTION 403. Is the facility located on In n Reservation or 405. <br /> L3.FARM El4.PROCESSOR El6.OTHER Trust lands? E] 1.Yes 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPE Y OWNER NAME p 407 PHONE 408 <br /> �a r <br /> MAILING ADDRESS 409. <br /> S S-z <br /> CITY 410 STATE 411. ZIP�� � � alz. <br /> CK <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. 1 PHONE 428-2. <br /> MAILING ADDRESS 4283. <br /> ICi GAJ <br /> CITY zsa. STATE 428 5 ZIP CODE 428-6. <br /> C 1C ,w C 5 2 2- <br /> IV. TANK OWNER INFORMATION <br /> TAN OWNER NAME 414. PHONE 415. <br /> Iii ( C1 uo) X21 -- L1-4-71 <br /> MAILING ADDRESS j <br /> 416. <br /> �S r <br /> CITY 412 TATE 418. ZIP CODE 419. <br /> S <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> ❑ 7.FEDERAL AGENCY 8.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 HOL ER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> 423: <br /> I_Ys.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I cern matin herein is true,accurate,and in full compliance with legal re . s. <br /> NT SIGNA DATE 424. PHONE _m 425. <br /> APPLICANT NAME(print) 426. APPLICANT TITLE a 427 <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />