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MEMEL- <br /> D PROGRAM CONSOLIDATED FORNO <br /> UNDERGROUND STORAGE TANK <br /> OPE TING PERAUT APPLICATION-FACUM INFORMATION <br /> (O a ftm per facility) <br /> TYPE OP ACTION [j1.NEW PERMIT ❑ S.CHANGE OF INFORMATION [17.PERMANENT FACILITY CLOSURE 400' <br /> (Cboelt one hm°"h') ❑ 3.RENEWAL PERMIT [16.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PBRMII <br /> L`FACII:ITh TIOS�i <br /> TOTAL NUMBER OF USTs AT FACILITY loft FAC[[ <br /> (.tRency Use O►+ly) <br /> BUSINESS NAME(swearAaLwyNAM orMA-Datna AP) 3. <br /> BUSINESS SITE ADDRESS CITY 104, <br /> FACO.FTY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ z FUEL DISTRIBUTION 409, Is lite facility basted ca Iadiaa Rapavatim or aa'.' <br /> 3.FARM Q 4.PROCESSOR Q 6.OTHER Trust lands? ❑Yes ❑No <br /> . ..... ..... .. •.:.. .. ,,...•.,. ..: . <br /> PROPERTY OWNER NAME 407. 4 <br /> PHONE �• <br /> MAILING ADDRESS 40, <br /> CITY Ila. STATE 411, ZIP CODE Q12. <br /> ;OP. TOR 6 <br /> III::°T. .. <br /> TANK OPERATOR NAME ^. PHONE 429.2 <br /> MAILING ADDRESS <br /> STTE 4ssCIIX <br /> :. ,INFO 'TION <br /> IV:...T. .® : . . <br /> TANK OWNER NAME ala. /PHONE Ali. <br /> l <br /> MAILING ADDRESS 416. <br /> CFIY 41_ STATE ae. ZIPCODB els. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ S.COUNTY AGENCY ❑ 6.STATE AGENCY 43D. <br /> ❑ 7.FEDERAL AGENCY ❑ S.NON-GOVERNMENT <br /> .. ..., . ., ... V; AM Oil.EQ� �•TIO ':�ST��... . ,GES. AC�O. ........ <br /> TY(TK)HQ Call the Stec Bowd of Equalization,Fuel I=Division,if dmsm gnestlom sat, <br /> VI Hbfi.D�R. TI <br /> ®N <br /> lam permit end send lcpl readfications sad mailing to. ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ S.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION.OR OFFICE MqWred For PublicOnly) aos. <br /> IC STGNA ,. <br /> MT[FICATION: I t6stt the Inf 6 manteol,and In fra8 ggoam with Ind rewdrewaft <br /> APPLICANT SIGNATURE DATE ata• 1 PHONE 425• <br /> APPLICANT NAME(print) 426. APPLICANTITME aZ7 <br /> ErPCF UST-A Rev.(12/2007) <br />