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1 0 0 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE 'TANK <br />OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br />(One form per facility) <br />I <br />TYPE OF ACTION ❑ 1. NEW PERMIT 5. CHANGE OF INFORMATION [:1 7. PERMANENT FACILITY CLOSURE <br />(Check one item only) <br />11� <br />400. <br />0 3. RENEWAL PERMIT [:] 6. TEMPORARY FACILITY CLOSURE 0 9. TRANSFER PERMIT <br />I- FACILITY INFORMATION <br />TOTAL NUMBER OF USTs AT FACILITY4"- <br />(0 <br />1 FACILITY ID N <br />1. <br />(Agency Use Only) <br />BUSINESS AME (Same as FACILITY NA o Da ing Rusincss As) <br />3. <br />BSINESS Sb A SS 103. <br />CITY <br />104, <br />FACILITY TYPE 1. MOTOR VEHICLE FUELING El 2. FUEL DISTRIBUTION 403. <br />Is the facility Located on Indi Reservation or <br />405. <br />ED] 3. FARM 0 4. PROCESSOR [j 6. OTHER <br />Trust lands? ❑ Yes No <br />11. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407. PHONE(0 <br />408. <br />m pqrhef (tol <br />-A- <br />AILING ADDRES4 <br />ii'97 <br />k10 4 �CITY.Lf "- <br />A 410] <br />STATE 7TT- <br />ZIP CODE <br />412. <br />\j <br />M. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 4284. PHONE <br />428-2 <br />I N A <br />428.3 <br />CI% ve* <br />4284 <br />S-yATE 429-5 <br />AL <br />ZIP CODE <br />429-6 <br />JANK OWNER2ORMATION <br />TANK OWNER NA 414.- P116NE <br />4157 <br />00 <br />IL A REfi <br />416, <br />CITY 417. <br />418. <br />ZIP CODE <br />419. <br />mc:7!� <br />03 <br />OWNER TM. [1 4. LOCAL AGENCY/DISTRICT ❑ 5. CON <br />_W AGENCY r) 6. STATE AGENCY <br />420. <br />C3 7. FEDERAL AGENCY B. NON-GOVERNMENT <br />V. BOARD OF EQUALIZATION ST STORAGE FEE ACCOUNT`NUMBER <br />Ty UK) RQ 44- J!�, I Call the State Board of Equalization, Fuel Tax Division, if there are questions. <br />421, <br />VL PERMIT HOLDER INFORMATION <br />Issue permit and send legal notifications and mailings to; ❑ 1. FACILITY OWNER )94. TANK OPERATOR <br />423 <br />El 3. TANK OWNER 0 5. FACILITY OPERATOR <br />SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies Only) <br />406. <br />V11. APPLICANT SIGNATURE <br />CERTIFICATION:thatation <br />CERTIFICATION: I c of that the info ation,provided herein is true, accurate, and in full compliance with legal reguirements. <br />APPLICANT SIGNATUR DATE 'ff'A 424. 1 PHONE 425. <br />01 )o?9� --_7PI? <br />APP A k ri 426. nPQ[%TTITW-- <br />417 <br />UPC' UST -A Rev, (12/2007) <br />