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From 11/03/2008 15°35 #164 P 014/033 <br /> /t <br /> )"95 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION- FACILITY INFORMATION <br /> (Otte form per facility) <br /> TYPE OF ACTION 19 1-NEW PERMIT ❑ 3.CHANGE OF INFORMATION 400. <br /> (Check one irem oily) © ?.PERMANENT FACILITY CLOSURE <br /> Q 3.RENEWAL PERMIT Q 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404 FACILITY ID N <br /> � 3(Agency Use Only) <br /> BUS ESS NAME(Same as Facility Nivae or DBA—Doing Business As) <br /> s � <br /> r <br /> BUSINESS SITE ADDRBS io3 CITY T04 <br /> . .5 Tic lZri Fr(/ ;� -/z In <br /> FACILITY TYPE -;K I MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or 405 <br /> El 3.FARM ❑ 4.PROCESSOR Ej 6.OTHER Trust lands? ❑ 1.yes 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME ��ous . 407 PHONE aes <br /> �.. t-L�SAH <br /> MAILING ADDRESS <br /> 409 <br /> CITY 41e 1 STATE 411 ZIP CObE 412 <br /> CA <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428.1 PHONE 428.2 <br /> MAILING ADDRESS <br /> 628.3 <br /> CITY 4284 1 STATE 423.5 1 ZIP CODE 428.6. <br /> to �6� 5�3� <br /> IV, TANK OWNER INFORMATION <br /> TANK OWNER NAME614 PHONE 416 <br /> MAILIN ADDRESS UL 14 <br /> 4l6 <br /> CITY 417 STATE =q5-;z-g <br /> 419 <br /> L)vf,A& A M <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ S.COUNTY AGENCY ❑ 6.STATE 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 of Equalization,Fuel Tax Division,if there are questions. 421 <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue pernutand send legal notifications and tnailings to: XI.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Pu8lic.tgencies Only) 400 <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: l certify that the information provided herein is true accurat and in full com liance with legal <br /> � re uirements. <br /> APP T SIGNA DATE424 PHONA <br /> APPLICANTNA E(print)oP' 426 APPLICANTTITLE 422 <br /> UPCF UST-A Rev.(12/2807)-1/2 www.unidocs.org <br />