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Oq RECC R D , UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK DEC 4 2009 1410 OPERATING PERNIIT APPLICATION-FACILITY INFOR 4M TYPE OF ACTION I.NEW PERMIT ❑ 7.PERMANENT FACILITY CLOSUR Ij J1X1- �/ ❑ 5.CHANGE OF INFORMATION (Check one item only) A�3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF USTs AT FACILITY 404 1 FACILITY IDN _ _ j 1. (Agency Use Only) J D BUSINESS NAME( Borne u FACILITY NAME or DSA C-Doing Basions As) J. I. 1 1 V BUSINESS SITE ADDREm3. IN 140 C&II or 1 ` Y J9 953d-6 FACILITY TYPE t.MOTOR VEHICLE FUELINGJ13 . ❑ 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or 405 ❑ 3.FARM ❑ 4.PROCESSOR 6.OTHER Trust lands? ❑Yes ila}Jo Fit.)PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 40t PHONE 408. C e- 0 0 83 9- 9 MAILING ADDRESS 409, 1 do e tAn; CITYc G^ IAh 4�0 STATE 411 ZIP CODE 412, J 4l/ III. TANK OPERATOR INFORMATION TANK OPERATOR NAME 428-1. PHONE 428-2 MAILIN ADDRESS 428-3 243 CITY 4284 1 STATE 4'-x s ZIP DE 428+ 1 IV. TANK OWNER INFORMATION TAN L WNER NA E 414 PHONE 415. ( > 3 / MAILINGADDRES 416. CITY -So 417. 1 STATE 418. ZIP COD 410. In OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4211 ❑ 7.FEDERAL AGENCY 01j.NON-GOVERNMENT / V BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421_ VL PERMIT HOLDER INFORMATION Issue permit and send legal notifications and mailings to: 1.FACILITY OWNER 4" Pe B B ❑ 4.TANK OPERATOR 3.TANK OWNER ❑ 5.FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 466 VII. APPLICANT SIGNATURE CERTIF ATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. APPLIC SIG.NAT E DATE a 424 PHONE 425 -� - 0 93 -'I6 1U—PL1 ANT NA print) 1 J26 APPLIC N TrlL 4n 1 Jftlo UPCF UST-A Rev.(12/2007)