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0 4 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK V <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATIONa/�/�a <br /> e fo r foci Ity) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE ryry 47 <br /> (Check one item only) ❑ g RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 400' FACILITY ID N _ _ + '1 q 1 <br /> (Agency Use Only) <br /> BUSINESS NAME(s.nne..FACn.ITY NAME m 9A-Doing aunnen As) 1 3. <br /> ec S i nfC EES �"1�fF�E(, LAzA <br /> BUSINESS SIT ADDRESS 15b-)0 <br /> 5 / -)0 9 A Q L/t,. 1 00 <br /> 103. CITY LAT <br /> A T- /()D t00 <br /> FACILITY TYPE L MOTOR VEHICLE FUELING [1 22..FUELDISTRIBUTION7N 4m' Is the faci(Iityy located on Iln�di 1Reservation of 4°s' <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? []Yes di <br /> R INFORMATION <br /> PROPERTY OWNER NA It�` `I�.r��� /^ ���O-r- 40J HONE n O� 408- <br /> MAILING ADDRESS i� w J J I OJT 409 <br /> 1S6�n oA0 <br /> CITY (�jT �r A � RI�.�n 4t0. STATE CA 411 ZIP CODE /] (2�6 412. <br /> IlJ,J <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME I A U,-Wp I ,( D E�K C -1>HGO—(' 4za-1. pHOVE 5' 1'1O b 428- <br /> Sz <br /> MAILINGADDRESS , A ALAN <br /> RG lk D \ n2x3 <br /> CITY �.r+ -OP J j'C 4284 STATE CA428-5 ZIP CODE 95330 428a <br /> IV. TANK OWNER INFORMATION �(y <br /> TANK OWNER NAME SIW Iw' DG� OG� 41 HAL I <br /> MAILING ADDRESS Cf�/ 1`r S / 00 <br /> 19. <br /> CITY Tl 9o,Qp 43t STATE G 418. ZIP CODE 3�b 410. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.C GENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY 8.NON-GOVERNME <br /> V. BOARD OF/EQUALIZATION UST ACCOUNT NUMBER <br /> TY(TK)HQ 44- a / E� Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLD R INFORMATION <br /> 3 <br /> Issue permit and send legal notifications and mailings to: 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> Tm- <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.AP ICANT SIGNATURE <br /> CERTIFICATION: I cern t at the' for tion r ed herein is true,accurate and' full m liance with legal requirements. <br /> APPLICANT SIGNATUREr DATE ` �� 430, PH. E� <br /> i/ <br /> wA '�S / 4M. APPLICANTTITL 4n <br /> APPLICANT NAME(print) � I//} /`r-'/a I V I <br /> UPCF UST-A Rev.(12/2007) <br />