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o V <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION [1 7. <br /> 7.PERMANENT FACILrrY CLOSURE 40p' <br /> (Cheek One 1t..mlv) ❑ 3.RENEWAL PERMIT C16.TEMPORARY FACILrrY CLOSURE X 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT m FACILII YwIAL4a' FAC D#ID# © <br /> - (Agenry Use only) I <br /> BUSINESS NAME(s as FACaNAME m DBA-Dasa sans As) 'J• <br /> Of)STS 1'N'I- 7R DTN(r Grz0VP, D ' 13-A1 OAST$ Q1Ia2A 1A2A Lige xvS fI) <br /> BUSINESS SrFE ADDRESS la. CITY la. <br /> OO ' C" cNEzaKeE LgNF I DI CA - 95240 <br /> FACILITYTYPE X1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Inrdsia1n Reservation or <br /> 3.FARM 4.PROCESSOR 6.OTHER Trust lands? ❑Ycs F•1 No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME w7. PHONE aa. <br /> 13oti'�S 0A/N(ErL 206) <br /> MAILING ADDRESS ' <br /> 3G J`.�l L� 1X2. 1%J f✓ <br /> CITY i10 STATE ^�� ZIP CODE 41' <br /> Lo 0)0 cYa 95ZK6 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 461. PHONE 1- - 7 pv 4T <br /> /Y»yR��H RD - n NO (2o49 ) 36 8-'0/2 7 <br /> 4)s-J , <br /> MAILING ADDRESS <br /> 7A- Sri u T?v Uf > - L.J- <br /> CI.Iv42s-4 STATE 439-5 ZIP CODE 4234 <br /> z1.ao/ 1 64. 9S24f-> - <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> ,OA,`eoj DANCedR (2cx ) 368-L71z <br /> MAILING ADDRESS 4t& <br /> 417. STATE 41s. ZIP CODE 419. <br /> crrY LGf)? cr)- 9 ul6 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4'-0 <br /> ❑ 7.FEDERAL AGENCY 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44 Call the State Board of Equalisation,Fuel Tax Division,if there are questions. 431. <br /> VI.PERMIT HOLDER INFORMATION <br /> 431 <br /> Issue permit and send legal notifications and mailings to: ❑ I.FACILITY OWNER [14.TANK OPERATOR <br /> 1 ❑ 3.TANK OWNER >K5.FACILITY OPERATOR <br /> 9a. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> A/14 <br /> VH.APPLICANT SIGNATURE <br /> CERTIFICATION: I cerd that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APP ICANT SI ATURE DATE 434. PHONE 425 <br /> t�����//`JJ'`/^/, (b-z -055 7 <br /> APPLICANT NAME(print) 4'-e. APPLICAM TRLE 43] <br /> UPCF UST-A Rev.(12/2007) <br />