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X340o.��s5/yy <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION fJ I . NEW PBRMIT ❑ 5. CHANGE OF INFORMATION V'. 7. PERMANENT FACILITY CLOSURE 400' <br /> (Chock one item only) [] 3. RENEWALPERMIT ❑ 6. TEMPORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACII.ITY ID 11 <br /> (Agexey Use oxty) <br /> BUSINESSNAME (s7=FAca NAIv1E orDHA—Doing Burivx ) ;' <br /> BUSINESS SITE AA4I I�9l y 6� 103. CITY ` 104• <br /> .Y hi-`s•`•','- "ci . �T � , Gam. _ 953 <br /> FACILITY TYPE ❑ 1, MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 403' Is the facility localon Indian Reservation or 405. <br /> ❑ 3, FARM n 4. PROCESSOR 6. 011IDR Trust lands? ❑ Yes WNO <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER RNAE 40• 1 PHONE 4N, <br /> —MAILING 409, <br /> ": a til ifi �v ci, <br /> CITY 410, 1 STATE 411, ZIP CODE 412. <br /> 1 vacs _ C� ._ 2533 2 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 429.1. PHONE 4n 2 <br /> MAILINGADDRESS ♦ 42sa <br /> CITY �- 4294 STATE 42&5 1 ZIP CODE 42" <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE vs. <br /> MAILING ADDRE � i9 �'+ . � sem- •Q7� 416. <br /> CITY 417 1 ST 41$. ZIP CODE�,r.� 419, <br /> OWNER TYPE: 9_4. L&AL AGENCY/DISTRICT ❑ 5. COUNTY AGENCY ❑ 6. STARE AGENCY 420• <br /> ❑ 7. FEDERAL AGENCY ❑ S. NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY (TK) HQ 44_ Call the State Board ofl3qualintion, Fuel Tax Division, ifthere are questions. 421' <br /> VL PERMIT HOLDER INFORMATION <br /> issue permit and send legal notifications and mailings W. :.I. FACILITY OWNER ❑ 4. TANK OPERATOR 4v <br /> ❑ 3. TANK OWNER ❑ 5. FACILITY OPERATOR <br /> 405. <br /> SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies Only) <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: J-cei;H ttiat thk information provided herein is true accurate, and in fall compliance with legal requirements. <br /> APPLICANT ZASIGNATU DATF, 424, PHONE <br /> 425. APPLICANT TITLE 427 <br /> �vIPP1=IC-Pd1� <br /> UPCF UST-A Rev. (12/2007) <br />