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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per fxility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT B�15.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 40a. <br /> (Cheek one am°ab) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY4a' FACILITY ID# _ — 1 <br /> (Agency Use OW <br /> ty) J <br /> 5. <br /> BUSINESS NAME(smea FACE NA o,]) A-Domenm m) <br /> 106 <br /> BUSINESS SRE ADDRESS toy. CITY <br /> FACILITY TYPE Er4.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION °m' Is the facility located on Ind' Reservation or <br /> nos. <br /> 3.FARM 4.PROCESSOR 6.OTHER Treat lands? ❑Yes No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4mI PHONE <br /> MAILING ADDRESSC!/' m0 4. <br /> CITY /' �j` STA,I'E rye su. ZIP CODE 9 a2 <br /> K 7 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 425-1. PHONE ° <br /> Sct <br /> MAILING ADDRESS °�; <br /> CRY 4264 1 STATE 429-5 ZIP CODE 42 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME ata. PHONE 415. <br /> 5 C ab d c <br /> MAILING ADDRESS 416' <br /> CRY 417. 1 STATE 416. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4za <br /> ❑ 7.FEDERAL AGENCY ❑ S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44_ Call the State Board of Equalisation,Fuel Tax Division,if there are questions. 421' <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue Permit and send legal notifications and mailings to: ❑ I.FACILITY OWNER ❑ 4.TAMC OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> aa. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the formation provided herein is true accunte,and is fuR compliance with legal requirementL <br /> APPLICANT SIGNATURE DATE j— u,/ aza. PHONE es. <br /> APPLICANT NAME(print) 3'r a APPLICANT TALE 427 <br /> UPCF UST-A Rev.(12/2007) <br />