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AbL <br /> UNIFIED PROGJ AM CONSOLIDATED FO" <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT Q 5.CHANG)r OF INFORWIATION 4oa. <br /> (th—le oar item only) ❑ �. PFRMANENT FACILITY CLOSURE <br /> 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ �,TRANSFER PERMIT <br /> L FACILITY INFORMATION <br /> TOTAL NUMBER OF USTS AT FACILITY 40a. <br /> FACILITY 1D ), <br /> (Agency Use 071110 <br /> BUSINESS NAME(SMI a FACiUTY NAW or DBA.mine H,..i wv A.) <br /> oe�,_/�ArC k 3.. <br /> BUSINESS SITE ADDRESS <br /> t ' h j� T CFry )oa. <br /> w P p � E- z��`7� <br /> FACILITY TYPE I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. <br /> 15 the facility locutcd on Indian Rtacrvation or <br /> El 3.FARM ❑ 6.PROCESSOR Q 6.OTHER gnat Iattds? �]Y� ❑No <br /> IL PROPERTY OWNER INFORMAT19N <br /> PROPf~RTY OWNER NAME 4M f.IiONE <br /> MAILING ADDR6S5 <br /> a)o. STATE� au. UP C <br /> III. TANK OPERATOR INFORMATIOi <br /> TA OR NAME 425.1. IfHONE 428-2 <br /> MAILING ADDRESS <br /> I aza-a <br /> CITY STATE Q8-5 <br /> 7 CODE 4234 <br /> 1V. TANK OWNER INFORMATION <br /> TANKTER NAME <br /> J 415. <br /> MAILING ADDRESS a 14 �) <br /> CITY 417. STATE 418• ZIP CODE <br /> ao, <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY <br /> ❑ 6.STATE AGENCY 420, <br /> ❑ 7.FEDERAL AGFN(Y 8.NON-GOVERNMENT <br /> Y BO <br /> ARD OF EQUpLI AVON UST STORAGE FEE AC 4j T <br /> TY(TK)HO 44 d b C5 NU11 ER <br /> Call clic su—Board of tquaiization,4'Uel Tat Division,if then are quant m, <br /> VL <br /> tivtt�wtti mat]fn s P>'iRMIT HOLDER: <br /> I>erutit and Bend Iegul notiY,�a g to: 1.FACILITY <br /> ORM <br /> Issue ❑ 423 <br /> 4,TANK OPERATOR <br /> ❑ 3.TANK OWNER Q 5,FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION.SECTION,OR OFFICE(Requital Fm Put4le AgtmCles Only) 406. <br /> V&"PLICANT SIGNATURE <br /> CERTIFICATION: I ce 'f that toe information provided herein is tcc <br /> APPLICANT SIGNATURE <br /> rue accurst and in full com lince with le aal r ttiremeAtb. <br /> DATE .za• <br /> PNUNE VI <br /> APPLICANT NAME(print) 16�. ��� —V <br /> a ^A APPLICANT TITLE 417 <br /> AA APPLICANT <br /> UPCF UST-A Rev.(IZaUU7) <br /> 68/9e 39dd GOOA SV9 3NO V 9L9L6686aZ ie:ze 60OZ/80/eT <br />