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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) T1 <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION [I 7.PERMANENT FACILITY CLOSURE <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 401' FACILITY ID# <br /> (Agency Use Only) ` <br /> BUSINESS NA me Facility Name or DBA-Doing Business As) <br /> -/ ;Cd LLL /!U j'2%COCEC/��7 <br /> BUSINESSSITE ADD CLTY ta. <br /> 4435. <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FLWdJNG ❑ 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR 0 6.OTHER Ttust Iands7 ❑ 1.Yes ❑ 2.No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NkME 4m. PHONE 4os. <br /> _ Jtl r� :; tri.'✓ �,.�iaO 1 J 15-A <br /> MAILING ADDRFaS 4ov. <br /> � ,k.= ��v� •nom Le�ce� <br /> C,,,1 no. STATE 411. ZIP CODE 411 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR N // azs-1. PHOpp14E 428-1/ /!d (� !D B{�(G�.taYM <br /> MAILING ADDRESS 43 3. <br /> /U eAII re <br /> CITY 4z STATE 4zs-s. ZIP CODE 4L 6. <br /> W. TANK OWNER INFORMATION <br /> TANK OWNER NAME / ` 414 PHONE 415. <br /> MAILING ADDRESS �/�y� �t � 41s. <br /> CITY _ j 417. 1 STATECIA4M ZIPCODF,,_ 41s. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(Tin HQ 4¢ 1 1 1 1 1 1 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER 4.TANK OPERATOR 413. <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Requiredfor Public Agencies Only) 406 <br /> VI.APPLICANT SIGNATURE <br /> CERTIFICA N: I jeCrtify that the information provided herein is true accurate and in ffijH compliance with legal reuirementL <br /> APPLIC SI DATE / 41. PHOjJl; 425. <br /> APPLICANT NAME riot)Z 426. APPLICANT E 1 4" <br /> UPCF UST-A Rim.(1=007)-112 -'` w .unidocs.org <br />