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U .f 2 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <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 40D. <br /> (Chock ane item only) ❑ 3,RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTI AT FACILITY a.a. FACILITY ID# <br /> I (Agency Use Only) <br /> BUSINESSNA (Same as Facility Name or DBA-Doing Business As) <br /> ttl/ 3. <br /> r 4 <br /> BUSINESS SITE ADDRESS rr l7� 103 CITY 1 /}C; <br /> IN/. <br /> —� 4�C n5'T'rfq 1J^V `1'A.-� �T ?zz)tv <br /> FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 493. Is the facility located on Indian Reservation or 405, <br /> ❑ 3.FARM ❑ 4.PROCESSOR '�B*.OTHER Trust lands? ❑ L Yes ❑ 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTYffOWNER NAME n /� 407. PHONE am. <br /> MAILING ADDRESSJ 409. <br /> C17;/ <br /> I 410. STATE 41' ZIP CODE 417 <br /> a�9 q5 0 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATTOR N,A1ME 429-1 PHONE 4x9-2_ <br /> lr -t4 Asim 953- O'7 t;'Cis/ <br /> MAILING ADDRESS 429.3, <br /> 11 <br /> 9tL� rel <br /> CITY 4234, 1 STATE a2aT ZIP CODE 4=+a <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME �+ a4. PHONE as. <br /> ~---,. L--dnS-4-rta-;4O <br /> MAILING ADDRESS n 416. <br /> CITY 417STATE au ZIP CODE ! SZ J uv. <br /> O G <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY(DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> ❑ 7.FEDERAL AGENCY $JI 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 Call the State Board of Equalization,Fuel'raz 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.TANK OPERATOR 427 <br /> '15 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) eo9. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424 PHONE 425. <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 127 <br /> UPCF UST-A Rev.(1212007)-1/2 www.unidocs.org <br />