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i-- <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.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 140W0, <br /> (Check one item only) ❑ 3.RENEWAL PERMIT El6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY iD# <br /> OiiE 0) (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> SANT -1Z A 44sz+ C oury rY- �o w,rl o PAR►4 G GHaAG� <br /> BUSINESS SITE ADDRESS 103. CITY 1�. <br /> 1 21 5. solei .V A6iu 1 5rQ-EE-rr 5-rDcic-row�� CA ciS2oz <br /> FACILITY TYPE jP�MOTOR VEHICLE FUELING El 2.FUEL DISTRIBUTION 403 Is the facility located on Indian R ervation or aos. <br /> E] 3.FARM [14.PROCESSOR ❑ 6.OTHER Trust lands? E] I.Yes o <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME PHONE 4°8. <br /> Counrry o¢ SPr+v �bA6tus►J�R�Qi s[ wo2►45`Fi.E�-r S�2�sa3 <br /> osrr�sz�r.1 2�Q 4-�8 -3 10(- <br /> MAILING ADDRESS 409. <br /> P.(>, Box %Boo <br /> CITY 4M STATE 411. ZIP CODE ail. <br /> S-rpc►c-,or.� CFl 4 52ol <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 PHONE 428-2. <br /> e_o"K--Y OP SRw)�DAqu19J /F�Se�T 5fr.QVXrxS 2-OR ) -446 -310!0 <br /> MAILING ADDRESS 428-3. <br /> P,o, t3oX 1$10 <br /> CITY 428-4. STATE 428-5. ZIP CODE 428-6. <br /> 51.00_G CA g S 20 t <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> eoutirly of S .�Apu�,,► lF�,��r 5£e �s *� ( 209 ) 4�8 -3Jo� <br /> MAILING ADDRESS 416. <br /> P.O , Box 1010 <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> 5-ro clrra N ejc� q s2o t <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT N15'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(TK)HQ 44- 17 Call 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 .TANK OPERATOR <br /> azs. <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Requiredfor Public Agencies Only) 406. <br /> DAKJ MG CitWtj Fl-f-eEx 5£1zVSZ9S MPOJA6r= 2 <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal re uireme" <br /> APPLICANT SIGNATU DATE 424. PHONESao, 425. <br /> 06/2-1 1200'? (2-09 <br /> 426. APPLICANT TITLE - 427 <br /> APPLICANT NAME(print) �1.Mq� <br /> C©Ltr W �u5'r�D C-3 <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs org Its <br />