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UNIFIED PROGRAM CONSOLIDATED FORM l 6 I3D/c3 <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE d00. <br /> (Check one item only) ❑ 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID k _ _ t <br /> w�" (Agency Use 0.1)') <br /> BUSINESS NAME(ssma..FACuM ru85ts c.DRA-Dot98 amiou.Aq 1. <br /> U URN UU SNC <br /> BUSINESS SITE ADDRESS 10` CITY IN. <br /> `i U 'Rol Lir ADP C - c15 0 1 L_AT K JZoP <br /> FACILITY TYPE O.1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION ... I Is the facility located on Indian Reservation or 405. <br /> 3.FARM 4.PROCESSOR Q 6.OTHER Trust lands? ❑Yes nNo <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> �jA T " < AM�1 (z <br /> MAILING ADDRESS 409. <br /> C7 C) 2 ed <br /> CITY 410. STATE 411. ZIP CODE 412, <br /> s t� v '-j1g6 <br /> III. TANK OPERATOR INFORMATION <br /> TANK0 RATORNAME 42F ppONE 42x-2 <br /> --t- <br /> MAILING <br /> ADDRESS 428-3 <br /> ,2-3o 6 e,( ova In <br /> CITY 4284STATE 428-5 ZIP CODE 429.6 <br /> 2oC)e- ., 61-) '76 S <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> W � <br /> A1 lG� o)-) <br /> MAILING ADDRES � r©C ,2 a16. <br /> & <br /> CITY 417. 1 STATE Ora, ZIP CODE 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- Cell the State Board of Equalization,Fuel Ta 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 /> ❑ 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 /> APPLICANT SIGNATURE DATE 424I <br /> 4PHgqONE 425. <br /> APPLI ANT NAME(print) 426. APPLICANT TITLE 427 <br /> UPCF UST-A Rev.(12/2007) <br />