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p.3 0 <br /> U..-r'IED PROGRAM CONSOLIDATED FORT <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> 400. <br /> TYPE OF ACTION ❑ I.NEW PERMIT ❑ S.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Check one icemonly) ( 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACII.ITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 40i. FACILITY ID ii <br /> (Agency Ure Only) 4 tl © Q <br /> BUSINESS NAME(Some as FACILITY NAME or D&4-Doing Busiinnm As) <br /> BUSINESS SITE ADDRESS L0' CITY 70` <br /> FACILITY TYPE 1.MOTOR VEHAO_.ICLE FUELING ❑ 2.FUEL DISTRIBUTION Is the facility located on In ian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 40T PHONE 406. <br /> Saq ch ti✓ FQd 4 1,' :3 5-3 2_6 <br /> 409. <br /> MAILING ADDRESS <br /> WL4_j/ OT <br /> CITY / % 41G. STATE alt ZIP CODE 412' <br /> t.t7 �l i <br /> III.: TANK OPERATOR INFORNIATION <br /> TANK OPERATOR NAME 428-1• PHONE 429-' <br /> r.W/ ( ao`,3' ) -36Y - .5-3' <br /> A2B-3 <br /> MAILING ADDRESS <br /> CITY 428-4 STATE42 1 ZIP CODE 426 <br /> 4) <br /> V. TANK OWNER INFORMATION <br /> TANK OWNER NAME 4ia. PHONE ats. <br /> 416. <br /> MAILING ADDRESS <br /> r i.lo <br /> 417. STATE 413 ZIP CODE 419 <br /> CITY 11 <br /> 4Cr e ��• �� � <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICTEl5.COL-NTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE,FEE.ACCOUNT NUMBER <br /> 421. <br /> TY(TIS)HQ 44- j(, G- Call tae Stale Board of Equalization,Fuel Tax Division,if there are questions. <br /> N71.PERMIT HOLDER INFORMATION <br /> 423 <br /> Issue permit and send legal notifications and mailings to: L FACILITY OWNER ❑ 4.TANK OPERATOR <br /> ❑ 3.TANKOWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I c rtifv that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT NA U DATE 424 PHONE aas. <br /> r <br /> APPLI�T_NAWE*(print) 426. APPLICANT TTTLE <br /> 4x7 <br /> UPCF UST-A Rev.(12/2007) 4 <br /> �,su iuLj � <br /> I <br />