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a <br />a <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 C1 7. PERMANENT FACILITY CLOSURE 400. <br />(Check one item only) ❑ 3. RENEWAL PERMIT ❑ 6. TEMPORARY FACILITY CLOSURE [1 9. TRANSFER PERMIT JAN <br />I. FACILITY INFORMATION <br />TOTAL NUMBER OF USTs AT FACILITY 414, <br />1 FACILITY D # <br />-3 <br />(Agency Use Only) <br />BUSINESS NAME (Same a FACUM NAME or DBA - Doing Business As) 3. <br />BUSINESS SITE ADDRESS 103. <br />CITY 104. <br />'w Liv 13 14 gra e'14 %/"3 3 6 <br />FACILITY TYPE 1. MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 403. <br />Is the facility located on Indian Reservation or 405. <br />3. FARM ❑ 4. PROCESSOR 6. OTHER <br />Trust lands? ❑ Yes ❑ No <br />H. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407-1 <br />PHONE 3 408. <br />(7,4/�00,?r4 <br />Li <br />MAILING ADDRESS 409. <br />3-30 <br />CITY 410. <br />1 STATE 411. <br />1 ZIP CODE 412. <br />HL TANK OPERATOR INFORMATION, <br />TANK OPERATOR NAME 428-1. 1 <br />1-114 150 T <br />PHONE 428-2 <br />(2 oel) ?-2 7--C,1 oil <br />MAILING ADDRESS 428-3 <br />// V �I) w <br />CITY 428-4 <br />STATE 428-5 <br />ZIP CODE 428-6 <br />1 <br />1 <br />IV. TANK OWNER INFORMATION <br />TANK OWNER NAME 414. <br />PHONE 415. <br />z <br />MAILING ADDRESS116. <br />i). e -i3ey lo,22- <br />CITY 417.) 1 <br />1�1 r/-, IT r=e +14 <br />STATE 418. 1 <br />61�9 <br />ZIP CODE 419. <br />/ s-33 6 <br />OWNER TYPE: 0 4. LOCAL AGENCY/DISTRICT ❑ 5. COUNTY AGENCY ❑ 6. STATE AGENCY 420. <br />❑ 7. FEDERAL AGENCY ;91"8- NON-GOVERNMENT <br />V. BOARD OF EQUALIZATIONUST 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: ❑ 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 />CERTIFICATION: I certify that the information provided herein is true, accurate, and in full compHance with legal requirements. <br />APPLICANT SIGNATURE <br />DATE 424. <br />PHONE 423. <br />1 'go <br />APPLICNAME (print) 426. <br />APPLICANT TITLE 427 <br />UPCF UST -A Rev. (12/2007) <br />