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Alk <br /> IFIED PROGRAM CONSOLIDATED FO <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION -FACILITY INFORMATION <br /> (One form per facility) <br /> 400. <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Check one item only) 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L FACILITY INFORMATION <br /> t. <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID 4 - - <br /> e (Agency Use Only) <br /> 3. <br /> BUSINESS=�e as Fac'ity Name OB/A Doing Business As) <br /> vi /' toa. <br /> 103. c �GK -wr) <br /> BUSINESS SITE ADDRES Ha it,mn ee�+ <br /> Vr 405. <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is[he facility located es Indian Reservation or <br /> Trost lands? ❑ 1.Yes2.No <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.0THER <br /> II. PROPERTY OWNER INFORMATION <br /> 407. PHONE 408. <br /> PROPERTY OWNER NAME <br /> 5)&o o0e aa9. <br /> MAILING ADDRESS /, <br /> K e ��l�� all. ZIP CODE <br /> CITY 2 a10. STATE / <br /> III. TANK OPERATOR INFORMATION <br /> 428-1. PHONE 42&2. <br /> TANK OPERAT NAME gale <br /> � - Dorms k ` z! �j �/! 7 <br /> (. ` , ) / O�J -J 4283. <br /> MAILING AD Sa41, /� i <br /> /f, 4za-5. ZIP CODE 428-6. <br /> azar. STA <br /> CITY ���///VVV��VVVV����II <br /> IV. TANK OWNER INFORMATION <br /> ata. PHONE 415. <br /> TANK OWNER NAME / <br /> .5 W J 416. <br /> MAILING ADDRESS <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY <br /> azo. <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER 42 <br /> 1. <br /> TY(TK)HQ 44- Q V Call the State Board of Equalization,Fuel Tax Division,if there are questions. <br /> VI.PERMIT HOLDER INFORMATION <br /> 413. <br /> ❑ 1.FACILITY OWNER 4.TANK OPERATOR <br /> Issue pemu[and send legal notifications and mailings to: 5.FACILITY OPERATOR <br /> ❑ 3.TANK OWNER ❑ <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agerccies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certif that the informatiroviderterein is true,accurate and in fuH co". lia nce HhOle al re uirements. azs <br /> APPLICANT SIGN91DZkC <br /> az6. APPyJ(,CANTfTLE <br /> APPLICANT NAME(print (//Oy! ' <br /> e C <br /> v►pis GGf <br /> UPCF UST-A Rev.(1212007)-112 www.unidoes.org <br />