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07/10/2009 10:34 20985850 TWO GUYS FOOD PAGE 03/08 <br /> 1�fD1 <br /> �IlaG� <br /> 4 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CSIANOE OF INFORMATION © 7.PERMANENT FACILITY CLOSURE 40�' <br /> (Check one item only) ❑ 3,RENEWAL PERMIT ❑ 6,TEMPORARY FACILITY CLOSURE ❑ 9,TRANSFER PERMIT <br /> L`FACzLITY INFORMA'T'ION <br /> TOTAL NUMBER OF USTs AT FACILITY °04 FACILITY 1D <br /> (Ayrncy Use Only) <br /> BUSINESS NAME($ame as radliiy Name or DBA—Doing Business As) <br /> TWO &UYS FOOP C+- V E L <br /> BUSINESS SITE ADD SS ins• CITY Ino. <br /> L-1}T R t11.fm P <br /> FACILITY TYPE SK t.MOTOR Vr•,HT. .F..FUELING Q 2.FUEL DISTRIBUTION 403' 14 the facility located on Indian Reservation or nog. <br /> 3.FARM 4.PROCESSOR ❑ 6,OTHER Trim lands-''❑ 1.Yes 2.No <br /> PROPERTYOWNER[N 'OIt1�IA-TXON : <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> CACM7 4 EN 'rf YLPrtasFJ' <br /> MAILING ADDRESS 409, <br /> P.0 B In( <br /> Z- <br /> CITY 4tn STATE ZIPCOVE 412. <br /> (y)ANT E C j4 c 9533(p <br /> IIL. .TANk OPERATOR INFORMATION <br /> 428.1. PHONE'. <br /> TANK OPERATOR NAME 128-1. <br /> MAILING ADDRESS n aZ8 a, <br /> CITY IL L I' .>�0' <br /> 428-4. STAT 4111 ZIP CODE <br /> - <br /> IV..'.TA bWNE1 INVOJIMAUON. <br /> TANK OWNER NAME 414. PHONE 415, <br /> AIV-Do jFN'TF-rZ-P94SES oo ) )w-v/v/ <br /> MAILING ADDRESS °1f'' <br /> p���z <br /> CT I y 417. STATE 618, 7.IP CODE 5334 419. <br /> 179A AZrf,4 <br /> OWNER TYPE: C] 4.LOCAL AGENCY/UIS'I RIOT ❑ S.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ($ R.NON-GOVERNMENT <br /> V:: LOA D t F'EQUALIZATION UST STORAGE FEE ACCOUNT'N'CJ'MB.F1'R:' <br /> TY(TK)HQ 44_ Pu Li O Call the State Board of F.quali7mion,Fuel Tax Division,inhere are questions. 421, <br /> PERMIT IIOLDER xNFURMA'�`IO�1`. ' <br /> 423, <br /> Issue permit and send legal notifications and mailing to: J4 1,FACILITY OWNER ❑ 4,TANK OPERATOR <br /> ❑ 3.'rANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required.far Public Agencies Only) 406• <br /> APPLICANT SIGNAT'U ` . <br /> CERTIFICATION: I certify at the information provided herein)is true accurate,and in fail com )lance with 1 t ulrementL <br /> CAdd4 SIGN ' RE DATE 424, PI4ONE 4U. <br /> 1) 7-7, ( ;Io 0/ 'y>"Y)u.b <br /> [,A NA .(pri07- <br /> 426, APPLICANT TITLE 437 <br /> R NAIL 14, ttY"l 503 pWnl>�R.. <br /> UPCF UST-A Rev.(12/2007).1/2 www.unidmq.org <br />