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Dec 09 2009 12: 27PM STCH MAINTENANCE 2098326070 p. 7 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One firm per facility) <br /> TYPE.OF ACTION ❑ 1.NEW FEP.MIT 5.CHANOE OF INFORMATI <br /> tcheckON ❑ 7,FEItM/INfiNT FACILITY CLOSURE <br /> oneimmomy) D 3,RENEWAL PERMIT <br /> ❑ 6.TSMPORAnY FACILITY CLgSURH ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER Op UFTe AT FAC- TY 44a FACILITY ID M J <br /> (agono),vie Ordl)9 — G <br /> 13U$INE NAME(gams as FACterrt'NAME ne o -pdni Badlumff & <br /> T. <br /> (' AA <br /> BUSINESSITEAb S C t <br /> 1103, <br /> � ` - r`iat� �• I Fa <br /> FACILITY TYPE ❑ 1,MOTOR L$FUELINQ ❑ 2.FUEL DISTRIBUTION 403' Is the eaoM a4ed on Indlsn Reservation or °Q$' <br /> 3.FARM 4.PItQCESSOR S.OTHER Trust lands? Q Yee No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNF j ,. 40PHO�� J u <br /> .S`u �e 3 <br /> MAILING l s5 <br /> 1 � . / /'�l� 409. <br /> CITY alo. <br /> STK19 alt. LIP OD <br /> e mc E -P6 35 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME PHONE aze. <br /> Ct <br /> MA[LIN4 $g, X1 , <br /> 2C—' <br /> CITY 42&4 STATEaaa. ZIPC0 E 42&6 <br /> IV. TANK OWNER INFORMATION. <br /> TANKOwNERNAME 4t4. PHONE 415 <br /> MAILING,-, <br /> 3 <br /> CITY 417, ATE 4ts. zipcO f 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 3.COUNTY AGENCY ❑ 6.STATE AGENCY 4N. <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT Xt. CEJ r^Ipsrc�f aK <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TX)HQ 44" Call the State Board of Equalization,Fuel Tax Division,iftbom we quesfiona. 421, <br /> VI..PERMIT BOLDER INFORMATION <br /> Issue permit and send legal notilicatlona and mailings to: O.1.FACILITY OWNER ❑ 4,TANK OPERATOR 4U <br /> J•3.TANK OWNER ❑ S.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required Per Public Agencles Only) <br /> VII.APPLICANT SIGNATURE. <br /> CERWIC ION: I cert that the formation rovlded herein Is tat euraft and In full Com Rance with al requirements. <br /> APPLICANT I NATURE DATE4 PHONE 42, <br /> %k B a a &ori t 3 A-C,43A <br /> APDL[ T NAME(p q r- 436. APP{LIC TITLE 427 <br /> AP( <br /> Q1n t 3 b <br /> UPCF UST-A Rev.(1213007) <br /> r� <br />