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At <br /> �Ds <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION � O <br /> (One Form ility) <br /> TYPE OF ACTION i1ir-1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400' <br /> (Check one item only) ❑ 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT C <br /> I. FACILITY INFORMATION <br /> TOTANUMBER OF USTs AT FACILITYFACILITY ID# <br /> (Agency Use Ony) O <br /> BUSINESS NAME(saneaFACRMNAM or DBA-Ds oinBurins As) 3• <br /> ���,o �blil i3 <br /> BUSINESS SITE ADDRESS L 103. C1TY _ 104. n, I(/ <br /> FACILITY TYPE MOTOR VEHICLE FUEL G ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM 0 4.PROCESSOR 0 6.OTHER Trust lands? ❑Yes No G <br /> II. PROPERTY OWNER INFORMATION a.j <br /> PROPERTY OWNER NAME 407- 1 PHONE 408. <br /> L��D <br /> MAILING ADDRESS 409• <br /> —1�� 'E: Lb�Z��3 <br /> CITY 410• STATE au• ZIP CODE 41z <br /> M. TANK OPERATOR INFORMATION <br /> TANY OPERATOR NAME 428-1• 1 PHONE 428-2 <br /> MAILING ADDRESS 428.3 <br /> 3 3 /a. <br /> CITY azg a STATE a2ss ZIP CODE 428-6 <br /> Ife <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME j 414. 1 PHONE j 415. <br /> MAILING DRESS 4165. <br /> CffY� f - 1--Vant8. ZIP <br /> . STATE— _t aCO�} � 7 419. <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- 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 /> t;;�-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 cone fiance with legal requirements. <br /> LICANT SIGNATURE DATE ata• PHONE 47S• <br /> Af ,;CANTN rint) 426. APPLICANT TA�LE _ 427 <br /> UPCF UST-A Rev.(12/2007) <br /> 1 <br />