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12/22/2011 15:08 2094640139 n�. rt^^•�� �� ^�"� <br /> UNIFIED PROGRAM CONSOLIDATED FORM T® <br /> UNDERGROUND STORAGE TANK Ell, <br /> C <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION }�, <br /> (Ore Fenn per k�, ry) 22 2011 <br /> IN <br /> TYPE OF ACTION ❑,��1 NEW PERMIT CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOMAR _, .1()A <br /> 13T � <br /> (0.1c mcilem WWI RPNPWALPERMIT ❑ 6.TEMPORARYFACILITYCLOSURE ❑ 9.TRANSFER PERMIT JF IN COUNTY <br /> /. FACILITY INFORMATION GENCV6ERVICE6 <br /> TOTAL NUMBER OF UST,AT FACILITY ('ACILRY Ib q <br /> (Agency Ux Onty) <br /> RIIS!NESS NAME(s�.".mrnrnrrr ran woan - a wn.nn <br /> BUSINESS SITE ADDRESS - CITY <br /> a �TIAL <br /> Zv <br /> TACILTTY TYPE [IZTWIOTOR VEHICLE FUELING ❑ 2.FLT.1.DISTR 8LMON Is the f ic,llty looted o Ian Re.ervation.r <br /> 3.FARM 4.FROCFSSOR ❑ 6.OTHER T,,A Innd.1 ❑Ycs 9;-w <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY0 RNAME ^"� PHOw- 9W. <br /> MAILING ADURESS <br /> CITY '1° STATE =DE <br /> CODE ^�= <br /> HL TANK OPERATOR INFORMATION <br /> TANKOPERATORNAME ^N.-I PH ^N" <br /> ✓pP J �� r/�J ( �) <br /> MAILING ADDRESS <br /> CITY .n TP CODE G r6. clo <br /> W. TANK OWNER INFORMATION /C� <br /> TANK OWNER NAME 414_ PHONE ns. <br /> �,.� o ( ., T, a� (2" f ff/ - 9//-T <br /> MA1L(h'G A. bRESS "Ic <br /> CT-.S S 1 <br /> Cf11' uI 1 VATE( Ot ZIP COD�, <br /> I J— 4t9 <br /> 2rrb . <br /> OWNER TYPE ❑ 4.LOCALAGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY ate <br /> 0 7 FEDERAL AGENCY p8.e NON-GOVERNMFXT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)w 44• Call the Scale 131o9rd ot'Equehzetim Fuel Tax Division.Ifthcrr are que..00rm el- <br /> VI.PERMIT HOLDER INFORMATION <br /> 199.0 Permit AlM 9md legal ootifiauom.nd mailmwI.. O I FACILTTYOWNER I$4.TANK OPERKfOR as <br /> ,C;�},TANK OWNER ❑ 5.FACILTTY OPFRATOR <br /> SUPERVISOR OF DIVISION.SECTION.OR OFFICE(Rcq.ired For Public Agcnac9 Only) .DR <br /> VII.APPLICANT SIGNATURE <br /> CERT IFICATIO : 1 certify(hat the information prumvided herein is true.a"wrate and in full com lance with legal requirentents. <br /> APPI_iCAM CrNA IREDATE / 1 l' 1 I'MIN <br /> 170 <br /> 4✓ /� <br /> APPLICANT NAME(pnt) �Ne APPLICA TALE ^N' <br /> U N• v" <br /> UPCF IW-A Rev.(12/31107) <br />