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Dee 05 11 05: 20p c�-s. �•, <br /> LA w <br /> a <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION(one form Per facility) <br /> TYPE OF ACTION CJ KEW PERMITX -01ANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Caedcoaabnmoaly) L0 3,RENEWAL PERMIT ❑ 6.TEiAPORARYFACR.C1'Y CLOSURE ❑ 9.TRANSFERPERMTT <br /> L F f E14MRMATION <br /> TOTAL NUMBER OF USTs ATFACILTTY 4a' FACQdTY ID I <br /> (dgaDiv Lha Only) 1 <br /> BUSINES$NAME(saaanPAcaIYn>uA-Dd�u(/ RM;) <br /> (V5ED <br /> CITY <br /> NESITAD $ <br /> 2N we-4, <br /> 9 . <br /> FACI.I7YTYPE Ii 1.MOTOR VEHICLE FUELING ❑ i FUEL DISTRIBUTION 4m' Is the fm'tib located oa Indian Rese vedea or <br /> Trost lands? ❑Yea $[No <br /> 3.FARM 4.PROCESSOR 6.l3THER --... <br /> IL PROPERTY,OWNERINFORAIATIOIN <br /> .. noes <br /> PROPERTY OWNER NAME am. PHONE <br /> SSf <br /> MAII.iNG ADDRESS �f <br /> J D f•r a C'`n i6r2avr'7 Q oyvt <br /> CITY 410. STATE 411. ZIP CODE a1z <br /> SkocV�ty» C•A 952►2. <br /> III 7 ANK•;OPFILATORJNFORMATION` <br /> TANK OPERATOR NAME am-1. PHONE _ <br /> SV ADDRESCr <br /> MA �j r, (rZc ) 9�El-1518 <br /> 438J <br /> ILING S <br /> 07 2, amo Gr <br /> CRY —UP—STATE. °ss's ZIP CODE <br /> '54 r+A <br /> IV. TANK OWNER INFOR14fATION <br /> TANK OWNER NAME 4t4. 'PHONE. - 415, <br /> 50LVNa — PI'S o <br /> 014 <br /> MAILING ADDRESS <br /> CITY an. STATE 414 ZIP CODE 419. <br /> OI NERTYPE' ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4m. <br /> ❑ 7.FEDERAL AGENCY ® S.NON-GOVERNMENT <br /> V BOARp'OF EQUA7 TZATIONUST STQRAGEJ. AC QUNTNUMBER, . <br /> .�. I 44- <br /> the State BoardofEqualizdon,Favi Tex Divi*,,ifd=arequstiom. 421. <br /> ...I _ <br /> VI.PEIt14iIT HQLDEdL.INFORMATION <br /> Issue permit and send legal notifications and mail'mgs to: ® 1.FACILITY OWNER ® 4.TANK OPERATOR <br /> ® 3.TANK OWNER 915.FACILITY OPERATOR <br /> ,a. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Balked For Public Agencies Daly) <br /> VIL APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information rovided herein!s trn ttccurat s>•d I..fan roBance with legg,requirvmentL <br /> APPLICANT SIGNATUREDATE f ^' 'I "r• PHONE / t <br /> r 1 `�-V✓�' - �dl�' I a2Ol <br /> aPPucAxrrrnm , <br /> APPLICANTNAME(prat) I,LI 01—Q' <br /> UPCF UST-A Rev.(IV2 07) <br /> t <br /> -_".J <br />