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PROGRAM CONSOLIDATED <br /> VW UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> �a (One fam par6t3hljrl <br /> TYPE OF ACTION ❑ 1.NEW PERMIT jMr4.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE v s J <br /> (Check one item°Oh') ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT ; <br /> L.: <br /> FACILITY INFORMATION <br /> TOTAL ER OF USTs AT FACILITY ' [FACILITY <br /> ID# <br /> (AgancY Use 0*1 _ <br /> 1A I 5T 1 1, <br /> BUSINESS NAMP(SmsFA IQAME - "' �-/ 3. <br /> C% 'Ten l j % t��t;�t Q - <br /> BUSINESS SIIE RESS f 1, u0. <br /> V 1 o (K `I7 Eu2. C1T Y i <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 406 Is the&C ty located an Indian/-'Resavation or a0Q` <br /> 3.FARM 0 4.PROCESSOR Q 6.OTHER Ttmt lands? ❑Yes ❑No <br /> IL:]PROPERTY OWNER INFORMATION <br /> PROPERTYOWNERNAMq PHONE 40L <br /> MAILING ADDRESS ( / ass. <br /> [ (\. (-O Ilk eelt <br /> CITY ata STATE <br /> � 411. T.iP CODE7-0 0 4M <br /> TIL'Tl N OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1- PHONE <br /> MAILING ADDRESS 428-3 <br /> CITY 429-4 STATE 4 ZIP CODE 42&6 <br /> IV. TANK"OWNER INFORMATION <br /> TANK OWNER NAME 7414 (P-HONE 411 <br /> MAILING ADDRESS 41& <br /> CITY 417. 1 STATE 414 ZIP CODE 411 <br /> OWNER TYPE: 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4m• <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V;:BOARD OF EQUALIZATION`:UST STORAOE:EEE ACCOUNT NUMBER -:' <br /> TY(TIC)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if these are qua 421' <br /> VLPERMIT HOLDER. <br /> INFORMATION <br /> Issue permit and scud legal notifications and mailing to: 1.FACII.ITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ S.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Raluired For Public Agencies Only) 40& <br /> VIL APP C SIGNATURE <br /> CERTMCATION: I certify that the information provided herein is trn accnra and in fall with low raph"WRIL <br /> APPLICANT IGNA DATE 4X PHONE 4x3 <br /> 3 1 I R/b 37 <br /> APPLICANT NAME t) 424 APPLICAN71JULEan <br /> UPCF UST A Rev.(1712007) u <br /> �;r <br />