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s <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <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 400 <br /> (Cheek one item.1y) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 4K FACILITY ID# <br /> i. <br /> (Agency Use Only) <br /> BUSINESS NAME!;:FAC AA -DRA-Doingltmin®As) <br /> Q4 3. <br /> " H rn,t Lk�i <br /> BUSINESS SITE ADDRES tai- CITY tm. <br /> FACILITY TYPE I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION a03' Is the facility located on Indian Reservation or 40. <br /> ❑ 3.FARM El 4.PROCESSOR 6.OTHER Trust lands? ❑Yes EANo <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY O ER NAME 407, PHONE 4oe. <br /> 5 a <br /> MAILING ADDRESS 409. <br /> 12 .1 <br /> CITY Oto. 1 STATE 411, ZIPCODE 412 <br /> SToo �4 c1SZo� <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 458-1. PHONE 458.2 <br /> MAILING ADDRESS 428-3 <br /> CITY �T�G�OY 4584 STATE 42e-5 ZIP�OD�E42e-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER Ne7 4147 1 PHONE 415, <br /> MAILING ADDRESS 4167 <br /> Y ftc <br /> CITY 417. 1 STATE 4197 1 ZIPCODE 4M <br /> � no o.�-� C�/� z�C <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY CP8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TIC)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 /> 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406' <br /> VIL APPLICANT SIGNATURE <br /> CERTIF[ the information provided herein is true accurate,and in full cont fiance with leXal requirements. <br /> APPLIC DATE 424. 1 PHONE 425. <br /> - ( Lo7 <br /> APPLICANT NAME(pri 45G APPLIC TITLE 4n <br /> UPCF UST-A Rev.(11J2007) � 4yr <br />