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0 pE z3 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One forth per facility) <br /> TYPE OF ACTION _ )71.NEW PERMIT El5.CHANGE OF INFORMATION 7.PERMANENT FACILITY CLOSURE 400" <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404 FACILITY 0 N _ _ 1. U <br /> (Agency Use Only) <br /> BUSINESS NA (s. FAcmm Arm or DBA-Doing Business As) 3. <br /> 1 <br /> a <br /> BUSINESS SITE ADDRESS 103. CITY IN, <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> 3.FARM ❑ 4.PROCESSOR EJ.6.OTHER LA L, CNS._ Trust lands? ❑Yes ❑No O <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 400- PHONE 408. <br /> MAILING ADDRESS 409- <br /> - O'er -J /oorr �Fa <br /> CITY L 410, STATE 411. ZIP CODE 412. <br /> ��1+e--- <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> MAILING ADDRESS 428-3 <br /> CITY 628-4 STATE 428-5 ZIP CODE 42x-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414_ PHONE 415, <br /> MAILING ADDRESS 416. <br /> CITY 417. STATE 418. ZIP CODE 419_ <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY .NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: I.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 /> CERTIFICATION: I certify that the information provided herein is true accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. 1 PHONE 425. <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> UPCF UST-A Rev.(12/2007) <br />