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FIED PROGRAM CONSOLIDATED FO 4-1I )-2- A:5 <br /> UNDERGROUNDSTORAGETANK 4 <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ I,NEW PERMIT Id 5.CHANGE OF INFORMATION 400 <br /> (Check one irem only) ❑ 7.PERMANENT FACILITY CLOSURE <br /> ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY °ta' FACILITY ID <br /> 3 (Agency Use Only) t� <br /> BUS ESS NAME(Same as Facility Name or DBA-Daing Busine <br /> ss As) 3. <br /> r ��L <br /> BUSINESS SITE ADDRESS 103. CITY / 04 <br /> N DCS . r c5-`/Ock&n <br /> FACILITY TYPE I.MOTOR VEHICLE FUELI 4113' 405. <br /> �, ❑ 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes J 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME mil. PHONE 408. <br /> 'Saln (ao ) - <br /> MAILING ADDRESS v <br /> / qtly <br /> 0 S Of4 (.c'a <br /> CITY 1 410. 1 STATE 411. 1 ZIP CODE 412. <br /> s4o C kt Uri l4 95 0 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2. <br /> T !" e cao ) a /ssv <br /> MAILING ADDRESS 428-3 <br /> Ob St A , ur E ZJr,c <br /> CITY // 428-4. STATE 428-5. ZIP CODE alx-e. <br /> cs t0 G k r, C` �,D <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME / m4. PHONE 415. <br /> S n t C T (a0 ) �J' r�� /SSr� <br /> MAILING ADDRESS 416 <br /> CITY U 417. 1 STATE419. ZIP CODE 411. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <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 Equalization,Fuel Tax Division,if there are questions. 021' <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue perunt and send legal notifications and mailings to: ❑ I,FACILITY OWNER 4.TANK OPERATOR 4a <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 06, <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify thO the 46urnation Drovided herein is true accurate and in full compliance with legal requirements. <br /> PPLI S GNATURE 3ATE � "ZS 4+4 P 425. <br /> (F ) ��_ S`-'V <br /> APPLICANT (p'nt) °'-5 APPLICAN .II LEI 4n <br /> �l C. Mrv,)-) I<S cE �m�1rl �G <br /> UPCF UST•A Rev.(12/2007).1/2 www.unidocs.org <br />