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Dee 22' 10 09:15a Bev (209) 462-9861 p.2 <br /> 12/21/2010 TUE 13:25 FAX 2094 3 SJC SHD <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One folrn.)er facility) <br /> ' , {LNWl'sW'AI, Ut RMAT . hh <br /> ,rRMANENT FACII. <br /> rl'Y CLOSURE ate <br /> ' <br /> TYPSOF Ac'RCN RMII• 5,CHANGE or INF <br /> } :vPORA2Y A I.ITY CLOSURE Q 9.TRANSIER FERN? ' <br /> PP.RMt'I' [3 &TICene ileouYJ RCOR <br /> t <br /> ad" FACILITY Ill 1, <br /> "CO'!'AL NUMDE:R OF JSTs A"f FACl1.11'Y — <br /> (Agency Use Gealy) <br /> BUSIN7SSNAM1 (ScuncrlrFacili 'Nan+ DSA-Dohs i3:rri+ .rs <br /> t 4,c- 4i/eZiCS <br /> CITY _ <br /> BUSINESS STIT:ADI)R::SS�� •� �- �--�' <br /> G / � do3 <br /> FACILITY TYPE- Q i.MOTOR vEHICLE I:UELING ❑ 2.1-ULL DISTRIBUTION 03 stile facility located on Ind[ n Reservation or <br /> d.PROCESSOR ,6.OTHM Crust lands" 9. 2-No <br /> ❑ S.FARM ...... 7. - <br /> A�lr�:a�1 <br /> O <br /> �V <br /> yy�7�g'{'�p.L1 <br /> 1'. <br /> ao7. .�l{pNE <br /> PROI'liWfY OWNER NAME <br /> -t L <br /> CrcY ate. STATE <br /> dtt I <br /> Sze <br /> o >zox TzoN <br /> x� . .. <br /> ,azsa. FIGNL' azaa <br /> TANKOPI'i A'fO .s <br /> G�s 6283. <br /> MAILING A7DR� <br /> CITY <br /> 428.4. STATE 42877 <br /> „!1CO ._8 <br /> ll <br /> Q <br /> m <br /> I E N7 <br /> 41'x• �:^y:'". <br /> .AP <br /> -_...,:.:,;:....:....:...............:..:. ... . .... ... <br /> 414 415 , <br /> •rANKO'�+NL•R NAME /� �� PHOI\1? <br /> MAi[.LrtG nDDRl:ss <br /> CITY <br /> - � a». STATG A, ala. 7_9P CODL ,.r � 414 <br /> OWNF,RTi'PE: OCALAGENCYXHSTII CT C] S.CGUNTY.IOENCY ❑ 6.5'CATiiAGIiNCY <br /> 6M. <br /> [j 7.FEDERAL AGEMY ❑ S.Nchq-GOVERNMCNT <br /> :.:.::...:.:::::';::,V.;;B�-... .',..',Q,Zt•,�,�t.Q�' �f+.f��i'X�:�I„US�'.u�?,.,:.•..:.::,.:..:..,._..........t... ... .. . .. _ .. dal <br /> TY(TIO HQ 44- <br /> Ca!)the Siete Board of Equalization,Fue:'rax 1)ivisic+,if they-aro questions. <br /> Ikf <br /> �4-TANK OPERATOR <br /> ax <br /> Issue lurmit and said 1^�al rosifi�tions and mailings to: ❑ 1.FACILITY OWNER �_ <br /> ❑ 3.TANK OVVNI;R ❑ 5.FACILITY OPFiRA"1 OR <br /> 696. <br /> &UPERVISOR OF to)IVIS1ON,SL•C'C[ON,OR 0rfKI:(Re quireAfor publicfgel l6es 00 y) <br /> 'SIGN, TURE <br /> CERTIFICATION: I ccl-fifY daat the int'oranation Iwo idedcrena is true accurate,and in full coon fiance with legal re uirelnents. o:s. <br /> APPLICANT SIGNATJRC L`Al l 42 PHONE 1 � <br /> 'a �'�i 1� � C, <br /> e 4z5. APPLICAIq TITLE_ <br /> W dzr <br /> APl'I.1CAN 1'Nf.MF (printer �' f �� � <br /> UPCPUST-ARov.(1112007)-112 (� www.uuidoesorg <br />