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VAN DE POL Fax:2094661910 Dec 23 2009 11:14 P.05 <br />0 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUNDSTORAGETANK <br />OPERATING PERMIT APPLICATION — FACILITY INFORMATION <br />(One farm per facility) <br />TYPE OF ACTION (] I. NEW PERMIT ❑ S. CHANGE OF INFORMATION ❑ 7. PERMANENT FACILITY CLOSURE °w. <br />(Check one Hem oely) ❑ 3 RENEWAL PERMIT. ❑ 6. TEMPORARY FACILITY CLOSURE [3 9. TRANSFER PERMIT <br />i.' k�•P►CIt,IT1" IDtPQR1�IAT30N <br />TOTAL NUM13EROFUSTS AT FACILITY °00. <br />FACILITYID# <br />(ASmnY Use OrttyJ <br />_ <br />BUSINESS NAME(s.oe® CM=NAM6 artana-nelnsawlmnM) <br />� <br />2. <br />BUSINESS SITE ADDR89S �� im <br />Ctty_ ia4. <br />FACILITY TYPE I. MOTOR VISHICL FUELING ❑ 2. FUEL DISTRIBUTION 403' <br />Is the facility locatcd on hWian Rmservatioa or 403' <br />3. FARM 4, PROCESSOR 6. OTHER <br />Twt>311MIs7 Q Yf No <br />IT PRQPERT1f ;OVYNEIi IY+iF66tATtON <br />PRO RTY OWNER NAME 407. <br />_. <br />PHONE 409. <br />n 1 , <br />— 1 � <br />MAILING ADDRESSl 40% <br />Ci'iY °u. <br />STATE Ott• <br />ZIP CODE 412. <br />� <br />3 i,-TA1�tK bPER4FpR'INFORMATION', <br />TANK OPE TOR, <br />A�TOR NAME <br />PHONE a2ea <br />4/r <br />MAILING ADDRESS v- 429.3 <br />LI <br />r d <br />CITY���N *X04 1 <br />STAg, 4us <br />ZjpQQDS4=4 <br />><v: TANc:owNEz�;nvFO�taTIQN <br />TANF OWNER NAME V 414 <br />r. <br />PHONE ata. <br />INO ADDRESS' Ota, <br />C u7. I <br />STAT Ota <br />ZIP C ate. <br />OWNER TYPE: ❑ 4. LOCAL AGENCY/wTrurT5. COUNTY AGENCY ❑ G STATE AGENCY aM <br />Q 7. FEDERAL AGENCY S. NON-GOVERNMENT <br />. BQQF F Qt7ALI2ATIbN USTTORA6EF1. EK ACCOLtNT NUMBER <br />WWI- <br />TY (TK) HQ 44 Call the State Booty OfEgmliaation, Fuel Tax Division, ifthate= questions. cat. <br />IMP RbIIT I�OLI�Eit iNFORIVPATIf7N <br />issue permit and send legal notifications and maRhras to: ❑ 1. 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) 4Ca <br />VII. APPLICANT SIGNATURE <br />CERTIFICATION: I wrtiry that the information provided herein Is <br />ue. secursta, and in full tom ante with! vire rtsoM <br />APPLICANT SIGNATURE <br />DATE 426• PHONE 42s. <br />APPLICANT NAME (print) Orb• <br />APPLICANM ITILE <br />UPCF UST -A Rev. (1213007) <br />