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0 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.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OFUSTs AT FACILITY 404. FACILITY ID# _ _ l <br /> a (Agency Use Only) <br /> BUSINESS NAME(same as FACILITY NAME or DBA-Doing Business As) 3. <br /> u' L [. <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> wh f M emel <br /> 403. 405. <br /> FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR 6.OTHER Trust lands? ❑Yes No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408 <br /> R P 11-LC �a� 5 <br /> 409. <br /> MAILING ADDRESS <br /> aiE CAMp 2d <br /> CITY 410 STATE 411 ZIP CODE 412. <br /> MA-OlecA CA <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. 1 PHONE 428-2 <br /> lane FymS (a ) a, -3as-� <br /> 4283 <br /> MAILINO ADDRESS <br /> a��I �. F ►�cL, CA 1J <br /> CITY - . 4284 STATE 428-5 ZIP CODE 428.6 <br /> NCA s3 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> (,c Af I LLC I--15 <br /> 416. <br /> MAILING ADDRESS <br /> CITY E-. o� mlo <br /> ar1 STAT als. ZIP CODE <br /> 419 <br /> AIWCC, 5-33 L - <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY [X 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 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 ❑ 4.TANK OPERATOR <br /> 423 <br /> ❑ 3.TANK OWNER 5.FACILITY OPERATOR <br /> 406 <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE F. <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal re irertients. <br /> APPLICANT SIGNATURE DATE424. PHONE <br /> �- azs. <br /> \ <br /> �jv f3 ao na 3�ss <br /> APPLICANT NAME(prin) 426 APPLI NT TITLE 427 <br /> UPCF UST-A Rev.(12/2007) <br /> :r <br /> 1 <br />