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UNIFIED MOGRAM CO(NSOUDATBD FORM <br /> UrWERGROUND S FORAGE TANK <br /> OPLRATING PERMT APPLICATION--FACILITY INFORMATION <br /> (OM Lora,par fac(Ipy) <br /> 'rYPC OF AcnON <br /> 1.NEW PERMfI' El 5.CHANGE OF INFOiLMAT1(XJ Q )_PERMANENT fACILfI'Y CLOSURE <br /> (Cl..k—iw o y) ❑ 3.RENEWAL PFJWrr ❑ 6.]'EMPORARY FACILfTY CLOSURi: 0 9-TRANSFER PERMrT <br /> 1. FACILITY INFORMATION <br /> 'r01'Al,HVMlBER OF USTa AT FACILrTY 4!l FA ik.rrY(D s <br /> (4i-w the SMI <br /> BUSINESS NAME(sr+r a.FAQIliY MAW-PGA- � <br /> Food !�?a{r ('aro/� �-� <br /> BUSINFIS SFM ADDRESS to. CITY IN <br /> e AOL <br /> i'ACILrPY TYPE 1.MOTOR VEHICLE MELOC [3TI <br /> Z.FULL DIS rmauON 1$ik falo <br /> cility cated m Indian Reservalion o4' �S. <br /> 3.FARM 4.PROC139M 6,OTHER imom laodO ❑Yes CNO <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTYOWNI>tHAME 1, PHOIIIE <br /> MAILING ADDP4LA 409, <br /> — <br /> .S �'. lnY1Gr+�v L��V�• <br /> CITY 4W TE 411, ZIP COOL '411 <br /> �v/nn�rhv��a 'f1v �tiy�ls <br /> Ul. TANK OPERATOR INFORMATION <br /> TANG OPERATOR NAME r. PHONE <br /> MAILM ADDRW 42111.' <br /> It <br /> erry STATE 1 ZSP CODE 4'96 <br /> W h n Gynu"a 'o'- <br /> IV. <br /> vIV. TANK OWN9R INFORMATION <br /> TANK OWNESN M%mr 4m PHONE eis. <br /> Al r m Wic� /-cI � ( W-5-) lia3- sZ�i� <br /> MAltJNO 4 is <br /> MY 4n- STATT,. ZIPCO]E ai9. <br /> owNF.R•rrPr:: p 4.LOCAL AfXNCY/WTRlc r ❑ 5.(:OUNPY AGENCY ❑ 6_STATE AOIWY <br /> ❑ 7.FEDERAL AGENCY K>L NON-cov W <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44 CaR lbc Some Bond or Equatinb—.fr.at Tau Dmum,40=c are Qu=bowL <br /> VI.PERMIT HOLDER INFORMATION <br /> Issuc YYUL arld SCO rro(ifli=10W and ari 4>1 <br /> lra Mq•)! �b: �1.FACILITY UIUNrER ❑ 4.TANK OPERA <br /> ❑ 3.TANK OWNER ❑ S.FACILITY OPERATOR <br /> 3UPEItVl40R OT DIVISION,SECTION,(11t QmCE(Requ:ed For P4ri,iie ARmeies Ontf') <br /> 400. <br /> VII,APPLICANT SIGNATURE <br /> CFAMFICATION: 1 cmiffy haat 11(e iaNsaatioaevicted hareiis is tray soursle,sod is&M isam wilk LeffA requir-ea� W <br /> APPLICANT SIGNATURE DATE PRONE <br /> APPLICANT NAME(pr' } APPtJC 7jTLE 421 <br /> n Lw� <br /> UPCF UhrI'-A Rev.(12/2007) <br /> ZB Du-ed 3AdDc-1 .1vi +oDm'J3NNTil ZSZbEZ95LL E0 :BT 8007-/9Zi'80 <br />