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Jun 18 08 06:50p Allen Thoma 530-6 22-2275 p.2 <br /> UNII+IED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per fi c lity) <br /> TYPE OF ACTION ❑ L NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 440' <br /> 1� 0°G1L0ON) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE 9.TRANSFER PERMIT <br /> L FACIIITY INFORMATION <br /> TOTAL NUMBER OF USTS AT FACILITY ma' FACI.TTYIDti <br /> 2 regrary tl a oaly) - - <br /> BUSINESS NAME 0. <br /> DAS�S ;rjT- rR DSNfr GlWuP- D 4 A- 014515 9k ?- <br /> BUSINESS <br /> IRLA Li4iotWf 1} <br /> BUSINESS SITE ADDRESS 1N. 'Ivo <br /> ITY U IM- <br /> 00• S- CO3F&OKEE C.-HN.E LD/>> c61 ^ R5240 <br /> FACILITY TYPE Wt.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION °Or' IS the faciidy locand on Indian Reservation or ' <br /> Ej 3.FARM E3 4.PROCESSOR El 6.OTHER Tmst Imlb7 ❑Ys JaNo <br /> IL PROPERTY OWNERINFORMATION <br /> PROPERTY OWNER NAME • PHONE +04. <br /> RoNNs 00/vcE� 2v4 36.13--0127 <br /> MAILING ADDRESS 10°- <br /> 30 -%/Attey I>e ioE- <br /> CIIY 410. 1 STATE 411. ZTP CODE 41' <br /> Lon► c� 95-•Ll�b - <br /> III. TANK OPERATORINFORMATION <br /> TANK OPERATOR NAME 418-t. PHONE 6 - 76t7J •08"0' <br /> lY1�hHf�iirrH-F - - /! No (tog ) 368-0/27 <br /> MAILING ADDRESS 4ua <br /> 73rD sown# G'1&vzae&z;7 z"j. <br /> CITY +a+ STATE °N, ZIPCODE 4' <br /> Gaon �. 9Szq-,� <br /> W. TANK OWNER INFORMATION <br /> TANK OWNERNAME 414. PHONE 411 <br /> F,OAIAJ,C DHvcEaL (2 ) 3b8-D!z <br /> MAILING ADDRESS 41& <br /> x-30 V•94-L9 Ue <br /> CITY Ott- STATE +la ZIP CODE nv. <br /> Lop? cr} <br /> OWNFRTYPE- ❑ 4.LOCAL AGENCY(DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4m. <br /> ❑ 7.FEDERAL AGENCY 8.MON-GOVERNhIBNT <br /> V. BOARD OF.EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER: <br /> TY(TK)HQ 44_ Call the State Board ofEqualimtioo,Fml Tax Division,if there are questicus. 421. <br /> VL PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ I.FACILITY OWNER ❑ 4.TANK OPERATOR 4n <br /> ❑ 3.TANK OWNER ws.FACILITY OPERATOR <br /> 4ca <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Rcryired For Public Agenda Only) <br /> VM APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein in tra acctuate,and in full coon lienee with legal requirments. <br /> APP ICANI�5�1!NATURE DATE +24• PHONE 425. <br /> " <br /> 6_Z_ <br /> o� ((SM) ) 9/9-0-57 <br /> APPLICANT NAME(print) 426. APPLICANTTITLE 4-i <br /> UPCF UST-A Rev.(12/2007) <br />