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UNERED PROGRAM CONSOLIDATED FORINow <br /> bl w1irl <br /> UNDERGROUND STORAGE TANK <br /> 0 <br /> Uw <br /> ON <br /> OPERATING PERT APPLICATION—FACILITY INFORMATIPERMIT (one form per facility) <br /> mmmomommomon� <br /> TYPE OF ACTION 131.NEW PERMIT <br /> .CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Check oas 1"only) [3 3.RENEWAL PBRbI7' ❑ G TEMPORARY FACILITY CLOSURE 139.TRANSFER PERMIT <br /> L FACILITY E00RMATION <br /> TOTAL NUMBEROF VUSTs FACILITY 406' FACILITY oa*NI <br /> (Agency 3. <br /> BUSiNE S NAME(sscs"FAcnMNAfAE-DaA-notes asitm A.) <br /> 103. crry <br /> BUSINESS SITE ADDRESS f <br /> 40. Is tlm facility located on Indian Reservation or <br /> FACILITY TYPE I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTR®IJIION Tnat ids? Dyes S No <br /> 3.FARM 4.PROCESSOR <br /> II._PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME r ,7 " rl ao 1 A/�g3 -- 9s6 9 <br /> • .t�J/fJ/�i /LJ 7/9//Y aos. <br /> MAILING ADDRESS Zl Ve, 51OCK1441 �jJ 95 ��✓ATE 411.• 23PCODE 41z <br /> 41 STATE+1 <br /> cmr R `/',733p <br /> IIG TANK QPERATOR INFORMATION a1s 4 <br /> eu-t. PHONE <br /> TANK OPERATOR NAME <br /> Sea' //vDE.c' 448-3 <br /> MAILLINGGADDRESS <br /> Al 03His of? G'%• ZI�CODE 42" <br /> +x4 STATE <br /> CITY e.9 9.5.33 0 <br /> L/�T/ye'av <br /> IV. TANK OWNER.INFORMATION 413. <br /> 414... .PHONE <br /> TANK OWNER NAME <br /> 416. <br /> MpILIN6 ADDRESS <br /> 413. ZIP CODE 419. <br /> at. STATE <br /> L/; / �'�d, 410. <br /> OWNER TYPE: ❑ 4.LOCAL'AGENCY/DISTRICT 5.COUNTY AGENCY ❑ 6.STATE AGENCY <br /> ❑ 7.FEDERAL AGENCY ❑ S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> (TK"LIQ 44 O &/ S / Call 0e State Board of Egoalimtion.Fuel Tax Division,if there are questions. <br /> VI.PERI�IIT HOLDER INFORMATION 423 <br /> 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> Is me permit and send legal wdacadow and mailings to: D 5.FACILITY OPERATOR <br /> ❑ 3.TANK OWNER ant;. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies OnIY) <br /> VII.APPLICANT SIGNATURE <br /> em. PHONE <br /> CERTIFICATION: I cord that the informatlon rovided herein is DA urn and TE in fuH eom Ea.. with N al requirements... 423. <br /> ADPL ANT SI TU --� r• - ,� %r.' ��� � <br /> 4n <br /> 4' APPLICANT TITLE <br /> APPLICANT <br /> UPCF UST-A Rev.(12/2007) <br />