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1 0 0 ` . - <br /> UNIFIED PROGRAM CONSOLIDATED FO /� l � 61 7 <br /> UNDERGROUND STORAGE TANK lJ 1 tzult- <br /> OPERATING PERNHT APPLICATION-FACILITY I TION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> �� _, L FACILITY INFORMATION <br /> ® <br /> TOTAL NUOER OF USTs AT FACILITY 404• FACILITY ID# _ 1' <br /> (Agency Use Only) I d 6 1 ol -I "�l lc�I ST I <br /> BUSINESS N\ E(SmneasFAC 1TYNAMEor BA-Doi �suKssAs) ` / 3. <br /> C 1 a> `Cil Q f/ <br /> BUSINESS SITE DRESS 103. CITY 104. <br /> S LI � <br /> ,"% ^ c..o ICA <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ISTRIBUTION 403' Is the facility located on Indian Reservation or aos. <br /> 3.FARM 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ❑No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAM 407• PHONE 408. <br /> cr SA� <br /> MAILING ADDRESS t+ 409. <br /> CITY 410, ATE 411. ZIP CODE 412. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1• PHONE 428-2 <br /> MAILING ADDRESS 428-3 <br /> CITY 4284 1 STATE 428-5 ZIP CODE x28.6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> MAILING ADDRESS 416. <br /> CITY 41 STATE 418. ZIP CODE 419. <br /> OWNER TYPE: 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE-FEE ACCOUNT NUMBER <br /> TY(TIC)HQ 44- ZICall the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 1.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) 406. <br /> V t o Dir o <br /> VH.APPL C SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate and in full compliance with legal requirements. <br /> APPLICANT IGNATU DATE 424• PHONE 425. <br /> 31 �/G 2fq 37 2416 <br /> APPLICANT NAME rint) 426• APPLICANTTIXLE a27 <br /> u k. <br /> UPCF UST-A Rev.(12/2007) <br />