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qq -of <�� UNIFIED PROGRAM CONSOLIDATED FORM D10BDI829`7.3 9/z2 -:EK14000.UNDERGROUND STORAGE TANKg�� OPERATING PERMIT APPLICATION-FACILITY INFORMATION (One form per facilitS3 TYPE OF ACTION N:1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION El 7.PERMANENT FACILITY CLOSURE (Check one item only) ❑ 3 RENEWAL PERMITG 3 `3 ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF USTs AT FACILITY 4' FACILITY ID# _ _ /y 1 (Agency Use Only) `1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. ei V� TUC. iZ�. �/�./�'L✓. s f�C BUSINESS SITE ADDRESS' 103. ITY 104, FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. ❑ 3.FARM ❑ 4.PROCESSOR 6.OTHER 42. o.W• Trust lands? ❑Yes EAIo Ih PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407. PHONE 408. L"? L �uero.,� ��i X 37-f7S�c MAILING ADDRESS 409. �sas r✓- ci !�„-�d4� Ste. CITY 410. STATE 411. ZIP CODE TIT. S��-n ✓ �'� moi`S III. TANK OPERATOR INFORMATION TANK OPERATOR NAME 428-1. 1 PHONE 428-2 MAILING ADDRESS 428-3 X - CITY 428 ST//A�yT��E,, 4z8-s ZIPP CODE 428-6 IV. TANK OWNER INFORMATION TANK OWNER NAME 414, PHONE 415. G :r z '-'e (2-9 'F3 7-9$'G-- MAILING ADDRESS 0 -� 416. �l aS • /<'� /Jiro-.pv CITY 4171 STATE als. ZIP CODE 419. OWNER TYPE: ..LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY ago. ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. VI.PERMIT HOLDER INFORMATION Issue permit and send legal notifications and mailings to: L FACILITY OWNER ❑ 4.TANK OPERATOR 423 ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406 VII.APPLICANT SIGNATURE CERTIFICATION: I certify that the information provided herein is true,accurate,and in full com liance with le al re uiremeits. APPLICANT SIG TURE DATE 424. PHONE 425. APPLICAN NAME(print) 426. APPLICANT TITLE 427 jc Tdr. .!o igss r All z; /Ll .A UPCF UST-A Rev.(12/2007)