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ra <br />VAN DE POL <br />Fax:2094661910 <br />• <br />Feb 1 2010 9:18 <br />0 <br />P. 02 <br />UPCF UST -A Rev. (112007) <br />A <br />UNIFIED PROGRANI CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />OPE <br />TING PERMIT APPLICATION - FACILITY INFORMATION <br />(One Form Pu POeiliry) <br />TYPE OF ACITON ❑ 1. PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 7. PERMANENT FACILITY CLOSUR13 900' <br />(Clicck 060 sem 04M <br />❑ 3. AL PERMIT ❑ 6. TEMPORARY FACILITY CLOSURE ❑ 9, TRANSFER PERIOITI' <br />TOTAL NUMBER OF USTS AT FACILITY 400' <br />FACILITY IDk• <br />• 1.,: <br />(Agemv Use OWy) <br />BUSINESS NAME (s" Cmmlls�VBA-1a4vyBia�eea <br />G f�_ <br />A4 <br />BUSINESS SITE ADDRESS em• <br />C>T • laq <br />FACILITY TYPE ;, 1. MOTOVEMCLI FUELING ❑ 2. FUEL DISTRIBUTION 4m' <br />is the facility located on Indian Reservation or 4ox <br />3. F 4. PROCESSOR M . OTHER <br />'rust landa? ❑ Yea No <br />IK: E'RQpE1tTY OWl!F :3 N • <br />,• <br />y7.� .. ...:. <br />PRO TY OWNER NAME _ 407. PHONE <br />l <br />MAILING ADDM98 469. <br />`t <br />12>'60 L Nve— <br />.CITY AA410• <br />STATE 41t• <br />ZIPCODE 411 <br />1"C <br />4'I��ik�lI ,'F. A 't1.\'l'ZiK'MTIIDX <br />TANK OPERATOR NAME•.1 4 r• <br />PHONE <br />X01 r <br />Cwt) 4405 --,2�4 <br />MAILING ADDRESS 4aa <br />STATF,, <br />ZIP G(Q� <br />" SVr Trl1NIf'1}10m ,PiF� OIt1NyClION - II <br />TANK OWNER NAME ua <br />PHONE. 415. <br />V <br />Mg[LR`IO ADDRESS 4M <br />\1_L�J• <br />C 417, <br />STATA 413, <br />ZIP CC2Z` 41% <br />OWNER TYPE: ❑ 4. LO AL AGENCYIDISTRICT El S. COUNTY AGENCY ❑ 6. STATE AGENCY 420• <br />❑ 7. PMPAL AGENCY !; NON-GOVERNMENT <br />do., ACCO <br />TY (4 ) HQ 44 Call the Soft Bond ofEquaErffiiou• Fud Taa Division, ifthetesm queauou& 4a . <br />�y <br />p R 1 Pii Y�it IfiiF() 11IA1TON <br />'°a <br />:ald <br />imm Permit and 9®d lew Doti mailings tot C31. FACILITY OWNER ❑ 4, TANK OPERATOR <br />5(3. TANK OWNER Q S. FACILITY OPERATOR <br />SUPERVISOR OF DIVISION, SEMN. OR OFFICE(Rcquirad For Public Agencies OulY) <br />t'IL *PklaiCimSIGNATURE <br />CBRTWIC I certl tha eke iafoemedoo y" harda is <br />ea aeeurat and in full com Hance with legal e Wrements. <br />ADPL <br />DATE HONE <br />4a PHONE [� <br />•' `� 9(� <br />" 0 4=a <br />CANT TC1LE <br />.M 4:0 <br />UPCF UST -A Rev. (112007) <br />A <br />