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10/03/2007 09:38 00050 P.004 /021 <br /> g <br /> Y L (; <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERN[T APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE O1F ACTION ❑ 1.NEW PERMIT JKS.CHANGE OF INFORMATION ❑ 7.PERMANENT FACTL,TTY CLOSURE ao0. <br /> (Chock'o90 ima only) ❑ 3_RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMTT <br /> I: FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY FACILITY ID t <br /> (Age11Cy Use Only) <br /> BUSINESS NAME(Smm=FACMn Y NAME mDBA-Doieg tau..*A,) 37 <br /> FIA6) GiTy <br /> BUSINESS SITE �nn'P-9, � 103. CITY ) F, 1 104 <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBIMON 403• Is The Noility located on Tndian Reservation or 405' <br /> ❑ 3.FARM Ll 4.PROCESSOR ❑ 6-OTHER •frust landV ❑Yes No <br /> II._� .. <br /> OPERTY.OWNER INFORMATION. f✓ — <br /> ERTY OWNER NAME <br /> INC*ADDRESS .- a0g. <br /> Oto. STA att. �pCODE ate <br /> - 62 <br /> �- <br /> _ UL:.TANK OPERATOR INFORMATION <br /> TANK OPERATOR i�Q --- — —__ --_ __—._..__..._.. azsa. <br /> I PHONF. azg-z <br /> -1330 <br /> MATT TNG ADDRESS 4221. (A) 628.3 <br /> v <br /> _/ a%� STATE 422 ZIP COD _ 423-6 <br /> /,0i <br /> JAMNK OWNER 14AW ata PHONY ass. <br /> ADDRESS 4167 . <br /> CITY aiz STATE ass. ZIPC013E 419.7- <br /> Lam. <br /> OWNER TYPE: ❑ 4.LOCAL,AGENCY/D --❑-5,-COUNTY AGENe --------❑--STAIEAGENC- azo. <br /> ❑ 7.FEDERAL AGENCY ❑ S.NON-GOVERNMENT <br /> V..B.OA.ICII.00.EUAI RATION€IST STORAGE.FEE AC�OEJNT NUMBER <br /> Q <br /> TY(TK)HQ 44 Call the State Board of Egvaliration,Forel Tax Division.if there arc questions. 421' <br /> VI.,VERMFT HOLDER.I,XFORMATION <br /> Issue permit and send legl notificatiotls and mailings to: ❑ 1.FACILITY OWNER Q 4.TANK OPERATOR 423 <br /> .TANK OWNER D 5.FACTL17Y OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) nos. <br /> VII.APPLICANT SIGNATCZRE <br /> CERTIFICATION: that or on provided herein is true,aecnrate,and in full rn liaace withkTA requirements- <br /> APPLICANTSTG DATE 474, PHONE <br /> �•. <br /> 16 -7, �0 <br /> APPLIC (print) azb APP ANT TITLE azo <br /> 7 <br /> A <br /> UPCF UST-A Rev.(1212007) <br />