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All) <br /> UNIFIED PROGRAM CONSOLIDATED FORM !1 <br /> UNDERGROUND STORAGE TANK <br /> �'� <br /> E <br /> ERATING PERMIT APPLICATION - FACILITY INFORMATION. <br /> (One Form per facility) ``S <br /> 406 <br /> TYPE OF ACTION ❑ I.NEW PERMIT ❑ 5.CIIANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> Wheckone item wjlN Q'.3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER.PERMIT <br /> L FACILITY INFORMATION <br /> TOTAL NUMBER OF LISTS AT FACILITY stu <br /> FACILITYlI) <br /> iAgencv Use <br /> PJJS,NFK,tSS NAME(Sane as Facility•`dame or D8,4--Doing Business As) ' <br /> BUSINF .S SITE AD SSy — rt't CITY S\vhf ' <br /> FACILITY TYPE ❑ I'MOTOR V HICLE FUELING ❑ '_.FUEL DISTRIBUTION s" IS the facility located on Indian Rcserva[lOn Or 3l s <br /> 3.FARM 4.PROCESSOR F.OTHER Trust lands? ❑ I.Yes La-l'No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 147 PHONE. 469 <br /> MAILING ADDRES <br /> CITY sto- STATE sit ZIP CODE <br /> III. TANK OPERATOR INFORMATION <br /> TANK_ BATOR NAME -s PHONE <br /> MAILING ADDRES,Sr <br /> CITY J?S-;. STATE s's 5 "LIP DE 4,T., <br /> ZI <br /> IV. TANK OWNER INFORMATION <br /> TAN OWNER NAME 414, PHONI +E5 <br /> iD S <br /> MAILING ADDRESS see. <br /> CITY 417 STATE +ts. LIPCODE 411) <br /> (x CA <15 7-&'-7 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 3.COUNTY AGENCY ❑ 6.STATE AGENCY 4' <br /> ❑ 7.FEDERAL AGENCY 0-S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- . Call the State Board of Equalization.Fuet Tait Division,if there are yucstions. 11 <br /> 1 <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ L FACILITY OWNER ❑ 4.TANK OPERATOR <br /> TANK OWNER ❑ ?.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required Jor Atblic Ageircies Oniv) <br /> VII. APPLICANT SIGNATURE <br /> ER IC TI t . I ertifv that the information provided herein is true,accurate,and in full compliance with le al requirements. <br /> t t T"c, !)LIN DATE ;"4 PHONE s'+ <br /> ) <br /> Appr t .ANIT NAM tnrintl 4226 APPLIC T TITLE s=' <br /> VPCF UST-A Rev.(12/2407)-1l2 www.unidoc,.org <br />