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Y2/x"'r � <br /> UNIFIED PROGRAM CONSOLIDATED FORM r• �! `!i <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION- FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 4°0' <br /> (Check one item only) 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404 FACILITY lD# _ t' <br /> (.Agency Use Only) <br /> SS NAME(Same as Facility Name or DBA-Doing Business As) ,/) 3. <br /> BUS S SITE AD SS 103 CITY t04. <br /> FACILITY TYPE El1.MOTOR V HICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 405 <br /> FARM 0 4.PROCESSOR OTHER Trust lands? ❑ 1.Yes ®!''No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408. <br /> S-ro <br /> MAILING ADDRESA 409. <br /> CITY 410. 1 STATE ZIPCODE 412. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 4'-8-2 <br /> (a20 951 - g14L/ <br /> MAILING ADDRESS �i 428-3. <br /> s o U V a- <br /> CITY 428A. STATE 428-5- ZIP CODE 42". <br /> ii t <br /> IV. TANK OWNER INFORMATION <br /> TA WNER NAME 414. PHONE 41 <br /> MAILING ADDRESS416 <br /> CITY 417. STATE 418. 1 ZIP CODE 419. <br /> ►� Z <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> ❑ 7.FEDERAL AGENCY Imo.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY{T Q HQ 44- Call the State Board or Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue it and send legal notifications and mailings to: 423 <br /> perm g b ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> Q-rTANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Oniv) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate,and in full compliance with legal requirements. <br /> CANT SIGN TURE DATE ':' PI[ONE 4? <br /> �' 10 <br /> ANT NAM {pr' t) 426 APPLIC T TITLE 427 <br /> UPCF UST-A Rev.(1212007)-I/2 www.onidocs.org <br />