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231ro AAVoaAI551 <br /> PA 40 <br /> UNIFIED PROGRAM CONSOLIDATED FORM A/W - <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION . FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION '�j I. NEW PERMIT ❑ 5. CHANGE OF INFORMATION 'JW7. PERMANENT FACILITY CLOSURE 400' <br /> (Check one item only) ❑ S. RENEWAL PERMIT ❑ & TEMPORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTS AT FACILITY 40/' FACILITY IDN _ 1' <br /> I (Agenq Use Only) <br /> BUSINESSNANE (samen:rAc¢ NA orDaA-bmugnureww ) s. <br /> BUSIN13SS SITE APDRES 102. CITY 104 <br /> �-` A t , . t, _ 9531 <br /> FACILITY TYPE ❑ 1, MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION is the facility loc on Indian Reservation or +os. <br /> ❑ 3. FARM ❑ 4. PROCESSOR 6. OTHER Trust lands? ❑ Yes WNO <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNERMkME , ✓�. 407. PHONE / 406• <br /> W ✓' <br /> MAILINGADDRESS 409, <br /> CITY +10. STA 7 CODE +12. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4284. PHONE <br /> �' 428-2 <br /> l" % <br /> MAILING ADDRESS > 4288 <br /> CITY �-- 42B4 STATE 42" ZIP CODE 42" <br /> r IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 9 414. PHONE 411 <br /> o �t Y'"' cob,?) <br /> MAWG ADDRES416. <br /> CITY �--� 417. 1 STATE 418. ZIP C(E ...� � 419. <br /> OWNER TYPE: 93. LdCAL AGENCY/DISTRICT ❑ 54 COUNTY AGENCY ❑ 6. STAT AGENCY 420• <br /> 7. FEDERAL AGENCY ❑ S. NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY (TK) HQ 44- T I I I Call the State Board of Equalization, Fuel Tax Division, iftbequestions. 421' <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: :aj . FACILITY OWNER [14. TANK OPERATOR 427 <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: 1-eeffifv that thh information provided herein is true aceura e, and in full compliance with legal requirements. <br /> APPLICANT SIGNATUM425. <br /> =p{1.pI3C +26 APPLICAPMITME 427 <br /> UPCF UST-A Rev. (12)2007) �iA1.�� W U b Cko4z e4 , <br />