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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK n�� OPERATING PERMIT APPLICATION-FACILITY INFORMATION (One form per facility) TYPE OF ACTION ❑ 1.NEW PERMIT E9-5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF USTs AT FACILITY 404' FACILTfY ID# _ 1. Z (Agency Use Only) BUSINESS NAME(Sane as FACHHY NAME or DBA-Doing Business As) 3. t-j L- BUSINESS SITE ADDRESS 103. CITY 1047 t7VZ,- (SID� FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403• Is the facility located on Indian Reservation or 405. 3.FARM 0 4.PROCESSOR 0 6.OTHER Trust lands? ❑Yes ZNo II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME • PHONE 408. MAILING ADDRESS 409. CITY 410• STATE 411. ZIP CODE 412• III. TANK OPERATOR INFORMATION TANK OPERATOR NAME 428-1 PHONE 428-2 MAILING ADDRESS l 1 428-3 l� t CITY 4284STATE 428-5 ZIP CODE 1 428-6 IV. TANK OWNER INFORMATION TANK OWNER NAME ala. PHONE 415. ( t / MAILING ADDRESS l 416. CITY an. STATE 418. ZIP CODE 419. OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY ago. ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. VI.PERMIT HOLDER.INFORMATION Issue permit and send legal notifications and mailings to: 0-1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. VII.APPLICANT SIGNATURE CERTIFICATION: I certify that the information r"ded herein is true accurate,and in full com fiance with legal r uirementi. APPLICANT SIGNATURE \ DATE 424• PHONE -425. APP CANT NAME 'nt) 426- APPLICANT TITLE a UPCF UST-A Rev.(12/2007)