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mw IFIED PROGRAM CONSOLIDATED FORM OPERATING. PERMIT APPLICATION UNDERGROUND STORAGE �CII.ITy INFORMATION TYPE OF ACTION ❑ 1.NEW PERMIT (O"0{Om5 Pa fewL'ry) (chwkweitemwry) ❑ 3.RENEWAL PEfU1gH• )K 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY ❑ 6.TEMPORARY FACB.ITY CLOSURE C] 9CLOSURE.TRANSFER PERMIT _. TOTALNUMB L Ft1CII,ITy INFORMATION QF USTs AT FACB.TI'Y aa4. J\ FACIIdTY ID# BUSINESS NAME (4gency Use Od3'I (Same mFAGttdIy NAI�orDBA-D4mgn�¢z,u) !, ' > BUSINESS SITE ADDRESS J T M C T C F' Z n n. D z 2 Frov� to �. 77 CITY � � PDQ ta. FACILITY TYPE ,1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION ❑ 3.FARM ❑ 4.PROCESSO:1 Is f�Hily located on Indian Reservation m 905. ❑ 6.OTHER Trent lands? ❑Yes �No PROPERTY QwxER NAME II: PROPERTY OWNER INFORMATION .0 L e• J am. PHONE MAH-ING ADDRESS V P3v I 4oa. eS 410. . STATE 411. ZIP CODE 412. PERATOR IM TANK OPERATOR INFORMATION TANK ONAME —" N Ak\L 4ze t. PHONE azaz MAILING ADDRESS -\} • v 4u.4 STATE 42e-5 ZIP CODE 3 �G 4»� TANK OWNER NAME IV. TANJOWNER INFO RMATION Ne- (, '. ., . / 414 PHONE 915. MAILING ADDREss (7 i30 L*a V ( ) C 416 atx STATF) A/1 ate. ZIP CODE I`r/AGE �©fir T 479. OWNER TYPE: [14.LOCAL AGENCY/pISTRICT 117.FEDERAL AGENCY ❑ S.COUNTY AGENCY ❑ 6.STATE AGENCY am. _ �S.NON-GOVERNMENT TY(TK)HQ 44- V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER p� V u Call the State Board of Equaliauon,fuel Tax Divisio4 ifdnere are questions. 421. VL PERMIT$OLDER INFORIIIATION Issue Permit and send legal notifications and mai W to. x 1.FACILITY OWNER ❑ 4.TANK OPERATOR aD ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE (Required For Public Agencies Only) nos. CERTIFICATION• I ceVIL APPLICANT SIGNATURE that the information rovided herein is true,acen and in full com Bance wi �P.RbiCANT SIGN, th requirements. DATE PHONE D 425. PPI ICANT NAME pri t 4ze. APPLICANT TTTL L W L_ 427 UPCF UST-A Rev.(122007)