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R 1 <br /> 4 <br /> R <br /> UNIFIED PROGRAM CON:OLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT 915.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400' <br /> (Check One item O°ly) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILfI'Y ID# <br /> (Agency Use Only) <br /> BUSINESSNAME(SS�es FACTME NAw DBA—Doing Buri.As) 3• <br /> BUSINESS <br /> —SITE ADDRE (� yryl S 103. CITY 104. <br /> 0 . 'VtCT�� k1�. Lo-1D <br /> FACILITY TYPE Ejfl.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403• Is the facilitylocated on Ind' Reservation or 405' <br /> El 3.FARM 4.PROCESSOR 6.OTHER Trust lands? [I Yes <br /> [ No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME' 407• PHONE 408• <br /> - 2®9 36q--� q Sg <br /> MAILING ADDRESS <br /> CITY 410• STATE 411• ZIP CODE 411 <br /> M. TANK OPERATOR INFORMATION , <br /> TANK OPERATOR NAME 428-1. 1 PHONE 42&2 <br /> SvKKCKA�N St N C',V4 <br /> MAILING ADDRESS _ az8.3 <br /> ViCT09 <br /> CITY 4284 STAT � 4zs-s ZIP CODE 0, �t'l b 42M <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME S V c,K H C h Al � S ( N r"H ala. PHONE <br /> �) �(�-1 — n 9 � g els. <br /> MAILING ADDRESS _ \ 2 416• <br /> g �b • �' tCTb . <br /> CITY �T an• STATE als. 2IP CODFLl C—2� ® 419. <br /> r " J <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT �❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420• <br /> ❑ 7.FEDERAL AGENCY 4d a.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. alt. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: I.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) ' <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify t the information provided herein is tree accurate,and in fall cam limt with uirements. <br /> APPLICANT SIGNA e DATE,-,9 _j aza. PHONE au. <br /> 9 \ ® <br /> 771 <br /> APPLICANT NAME(print) au• APPLICANT TITLE <br /> �a L t <br /> UPCF UST-A Rev.(IV2007) <br />