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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 [7,77 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# I I <br /> +Z (Agency Use Only) <br /> BUSINES S NAME(Same as FACILrrY NAME or DBA-Doing Business As) 3 <br /> S C-1ft,C <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION a03. Is the facility located on Indian anon or 405. <br /> 3.FARM 4.PROCESSOR THER Trust lands? ❑Yes o <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. 1 PHONE 408. <br /> l.Rt.��t'o�+ A Lsir'E- �•�S-tfi 2c 9 ) 5 S 1��. <br /> MAILING ADDRESS 409• <br /> 1 6' <br /> CITY 410 STATE 411. 1 ZIP CODE 412. <br /> S1�C-ktvwl C ''r 5 iz Z <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1• PHONE 428-2 <br /> 5 <br /> MAILING ADDRESS 428-3 <br /> CITY 4284 1 STATE 428-5 ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> MAILING ADDRESS 416. <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5. NTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY .NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TIC)HQ 44- 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: FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.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 re uirements. <br /> ANT SIGNATURE DATE 424• 1 PHONE 425. <br /> 1 O ZCt - 0� Lo�i C, <br /> PLICANT NAME(print) 4'-6. APPLICANT TITLE 427 <br /> UPCF UST-A Rev.(12/2007) <br />