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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 OF USTs AT FACILITY 404' FACILITY ID# _ f.� ' L _ t. <br /> *j (Agency Use Only) AlA 1/ � � � b "l <br /> BUSINESS NAME(Same as FacilityN e or DBA-Doing Business As) 3. <br /> F Orn <br /> BUSINESS SITE ADDRESS n n � 103 CITY � tD4 <br /> FACILITY TYPE 211.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or aos. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes [5-2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> S. DHS Ju, GLS g3v $ 77 g <br /> MAILING ADDRESS 409 <br /> 2A1 30 To e- 10o <br /> 410. STATE 411. ZIP CODE 412. <br /> CITY � � � <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2. <br /> I,-� �- - Com°,<'U +� l ( I ) $ ILI - g <br /> MAILING ADDRESS 428-3. <br /> " 3O Tot? (0r,j4�,C P/e-1--kAA <br /> CITY 4'-2 STATE 428-5. ZIP CODE 428-6. <br /> T C4�} aid 3 7 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME Tt S' t it 4-1, 3 tit L (,L 414• PHONE 415. <br /> MAILING ADDRESS 4t6. <br /> 2-q 134 3o e to 'i�e <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.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- -!I I 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 /> TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406 <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. `M 9 <br /> APPLICANT SIGNATUREDATE 424. PHONE 425. <br /> _ -P e so g", <br /> APPLICANT NAME(print) <br /> 426. APPLICANT T LE 421L <br /> v4 u <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br /> i;:�'4Tf�tl'BP�tl <br />