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MAR. 1. 2010 9: 39AM AG ,SPANOS JET CTR NO. 689 P. 2 <br /> i IN <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (Onc farm per facility) <br /> TYPE OF ACTION ❑ L NEW PERMIT ❑ $,CHANGE OF INFORMATION ❑ 7,PERMANENT FACILITY CLOSURE 100' <br /> (Checkonolmmunly) y.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9,TRANSFER PERMIT <br /> I, FACILITY INFORMATION <br /> TOTAL MBER OF UST&AT FACILITY ' FACILIIYIbN _ t <br /> (Agency Uae Only) <br /> BUSINE N (SSwee FACn.31Y NAM[i arDHA-IJdm PmlRa ACj 37 <br /> !S G <br /> BUSINESS SITE ADD SS 107' CITY 101• <br /> a <br /> FACILITY TYFE $I.MOTOR VEHICLE FUBLIN El 2.FUEL DISTRIBUTION 4m" Is the fhoility located on Indian Rcscrvalion or d0a' <br /> 171, 3.FARM 0 4.PROCESSOR a 6.OTHER Trust lands? ❑Yes fitNo <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407• PHONE 404. <br /> S a9 V-/ssc7 <br /> MAILING ADDRESS <br /> CITY f10 STkTE 611• YIP CODE 412• <br /> S40el Ar-�Z 0 <br /> IIT. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME °21•• PHONE 4314 <br /> MAILING ADDRESS 4414 <br /> CITY 1 4'74STATE 411•1 ZIPCODE 428.0 <br /> ar <br /> IV. TANK OWNEkINFORMATION <br /> TANK OWNER NAME 414. PHONE 411. <br /> MAILING ADDRESS' <br /> 416. <br /> d S. ; r er a <br /> CIT / 417. STATE Ora. ZIPCODE 419. <br /> s-6or, k �o,J C0a, 7,1c%0 <br /> OWNERTYPE: ❑ 4,LOCAL AGENCY/DISTRICT ❑ S.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> Q 7.FEDERAL AGENCY ❑ S.NON-GOVERNMENT' <br /> V. BOARD OF EQUAWATION UST STORAGE FEE;ACCOUNT NUMBER . <br /> TY(TK)HQ I I Call the State Board of Equalization,Fuel Tax Division,if there are questions. 4zt. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue pemIt and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 923 <br /> ❑ 3.TANK OWNER ❑ 5,FACIL"OPERATOR <br /> 4°s. <br /> SUPERVISOR OF DIVISION.SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII;APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that t4e ihf aBaB provided herein is true,accurate and Irk full Com race with legal requirements. <br /> TURE DATE '3 IM1 I 434 PHONE ^ 411, <br /> APP E tint) ,n 4�• APPLICANTTITLE ��allVVll UI 4 <br /> UPCF UST-A Rev.(IY2007) �/ <br />