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-F©P-&"A <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> • OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION '0 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 4 FACILITY ID# _ _ t <br /> (Agency Use Only) <br /> BUSINESS NAME(Same m FACILMY NAME or DBA-Doing Business As) 3. <br /> ELS -S <br /> BUSINESS SITE ADDRESS 103, CITY 104. <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION ao3. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 4os. <br /> i�C7 C� GI <br /> MAILING ADDRESS 409. <br /> .71? k 4 S 1 RFS j <br /> CITY 410. 1 STATE 411. ZIP CODE 412, <br /> S <br /> To C.,/e-- • 0 r`; GA <br /> iII. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. 1 PHONE 428-2 <br /> MAILING ADDRESS 428-3 <br /> i1.7 w . P, +� s->i F: <br /> 428-0 STATE 77CODE CODE 428-6 <br /> CITY <br /> Se-4 <br /> T(UC(c.To IQ <br /> IV. TANK OWNER.INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> At" <br /> MAILING ADDRESS 416. <br /> CITY 417. 1 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- 1 1 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 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 <br /> CERTIFICATION: I certify th t the information provided herein is true accurate and in full com liance with legal re uirem nIlCA <br /> APPLICANT SIGNATURE DATE azo. PHONE ,���� azs. <br /> 10 - 06 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> JOE D/4 N &72A-K-) o"�Pj r- R- <br /> UPCF UST-A Rev.(12/2007) 1113 <br />