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Fpr/'A P, a <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 .CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 4oa. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACHXff INFORMATION <br /> TOTAL NUMBER OF USTs ATF II.ffY 40/' FACILITY ID q0' <br /> (Agency Use 0*) - (J - 1 f l <br /> BD$ NANA66E -poiec amaocuAs) 3. <br /> �ryry G li4c Al^ u <br /> B SS$ITEC DSS w7.94il tm. C Ta-1 1a. <br /> FACILITY TYPE1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION a07' Is the facility located on Indian Reservation or 405. <br /> 3.FARM 4.PROCESSOR 6.OTHER <br /> Trust lends? ❑Yes t[]Jx0 <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME fI 40+ PHONE 408. <br /> C/ '� q'+T A L Z-T <br /> c7 <br /> MAILING ADDRESS 409. <br /> S <br /> CITY/ �( 410 STATE 411. ZIP CODE 412. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 42&1. PHONE 42s-2 <br /> C-/ 2/ it <br /> MAILING ADDRESS 428-3 <br /> CITY 4� 1 STATE 41 ZIPCODE 42-3-8 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> MAILING ADDRESS 416. <br /> CITY Orn. 1 STATE 418. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4,LOCAL AGENCYI)ISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420, <br /> ❑ 7.FEDERAL AGENCY [!r-S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)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 seod 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 /> VII.APPLICANT SIGNATURE <br /> CERTIFI QN; I certiK that4ffie information provided herein is true,accurate,and in full compliance with legal requirements. <br /> AP= DATE 424. PHONE ,5. <br /> e <br /> �-� <br /> APPLJCAIJT NAME(pplit) 4'26. APPLICANT TITLE 4n <br /> Azi S, <br /> UPCF UST-A Rev.(17J2007) <br />