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UMUFUD PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br />(One form per facility) <br />TYPE OF ACTION 0 1. NEW PERMIT 5. CHANGE OF INFORMATION [1 7. PERMANENT FACILITY CLOSURE <br />4W. <br />(Check one item wily) 0 3. RENEWAL PERMrr 6. TEMPORARY FACILITY CLOSURE 0 9. TRANSFER PERMIT <br />I. FACILITY INFORMATION <br />TOTAL NUMBER OF USTs AT FAC LTTY 'Mm' <br />I FACILITY ID # <br />FTT <br />I <br />1. <br />(Agency Use Only) <br />BUSINESS NAME (Sme as Fiw&J3LX- WDBA - DoiAg Business As) <br />3. <br />J Ze, MALK7,41Z j <br />BUSINESS SITE ADDRESS / - / - , 103 <br />CITY <br />104. <br />6j -2C'9 69-9Z& <br />FACILITY TYPE 0 1. MOTOR VEHICLE FUELING 0 2. FUEL DISTRIBU13bN 403. <br />Is the facility located on IV Reservation or <br />405. <br />0 3. FARM 0 4. PROCESSOR 6. OTHER <br />Trust lands? 0 I. Yes 2. No <br />H. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 4m. <br />PHONE <br />409. <br />JAA1 :f"40111A) <br />MAILING ADDRESS <br />409 <br />CITY f 41 . <br />STA M 411* <br />ZIPCODE <br />412. <br />1 !ZU& <br />III. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 428-1, <br />PHONE <br />429-2, <br />jqpw <br />MAILING ADD RESS - - /4H-3, <br />14110 a "119a-4 <br />Crry / 4294 <br />STATE 429-5- <br />ZIP CODE <br />428-6. <br />AUI-7461P <br />W1 <br />IV. TANK OWNER INFORMATION <br />TANK OWNER NAME 414. <br />PHONE <br />415. <br />kiLr-k <br />o) - <br />'-yyl117pl) <br />MAILING AD15RESS <br />a-16 <br />CM 417- 1 <br />AM 149 <br />STATE 418- <br />14, <br />ZIP CODE <br />419. <br />OWNER TYPE: 0 4. LOCAL AGENCY/DISTRICT 0 S. COUNTY AGENCY 0 6, STATE AGENCY <br />420. <br />0 7. FEDERAL AGENCY ks- NON-GOVERNMENT <br />V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />Ty Call the State Board of Equalization, Fuel Tax Division, if there are questions. <br />421, <br />VI. PERMIT HOLDER INFORMATION <br />Issue pe -it and send legal notifications and mailings to: 1. FACILITY OWNER 0 4. TANK OPERATOR <br />)01 <br />423. <br />3. TANK OWNER 0 5. FACILITY OPERATOR <br />SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Req tiedf., P.blic,*.ci. Only) <br />406 <br />VIL APPLICANT SIGNATURE <br />CERTIFICATION: I certify that the information provilled herein is truf, accurate, and in full compliance W. legal uirements. <br />APPLICANT SIG DATE, 4 PHONE <br />717A� <br />425. <br />// <br />APPLICANT Nt 426. APPLICANT TITS vl--- - <br />V <br />'427 <br />7'r. V AJZ16!� A 111,4-7le"49 R"'OZ16C <br />UPCF UST -/Rev. (12=n - L7 www.waidOCLOrg <br />