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0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM I v <br /> UNDERGROUND STORAGE TANK 1 l <br /> OPERATING PERART APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT 5.CHANGE OF INFORMATION 400, <br /> /Check one item only) ❑ 7.PERMANENT FACILITY CLOSURE <br /> ❑ 3.RFNEWAL FERMI I ❑ 6.TFMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> TO'1:4L NUMBER OF WI-A. FACILITY - 404. j <br /> -� FACILITY ID# <br /> BUSINESS NAME (ABeA Use Only) I <br /> (Scone as Fac/ltty Nmne or DBA-DoingBasinemAs) <br /> BUSPIF_SS S1TE ADDRESS ' <br /> Ai <br /> FACILITY TYPE ® I.MOT R VEHICLE FUELING U1 y <br /> ❑ 2.FUEL DISTRIBUTION 403, Is the facility located on radian Reservation or 405' <br /> ❑ 3 FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lads? ❑ 1.Yes [A 2.No . <br /> PROPERTYOWNERNAME <br /> 40. PHONE 408. <br /> MAILING ADDRESS // Std 99S - DGo <br /> �`^7Co0 iNa.��J �CS �>✓ �J4 TC S�� 409. <br /> CITY �G Oto. STATE , / ut. ZIP CODE ate. <br /> q'S V <br /> TANKOPERATOR NA/ME .123_1 - <br /> ��q.�oJs/�_ PHONE G} 428-2. <br /> MAILING ADDRESS F <br /> G Zao 5�®tee✓;J All r3� 42Y5. <br /> CITY <br /> 300 <br /> 1V <br /> ��5 3r.�r21�o� 42e4. $TATEaze.s. ZIP CODE <br /> - G /J � 4384. <br /> i. <br /> TANK OWNER NAME - <br /> / 414. PHONE 415. <br /> ��q✓�ar�isis� /Gfolev,�f, -: ve (�i25 ) o9- 4o z-5 <br /> MAII,INGADDRESS ,y <br /> IP ZC� S fOr✓G✓o� G / �tGI I�� ,S✓. �G ��O cry 416. <br /> CITY �jCq �.5.✓7'"0,✓ Ott. STATE�� eta. ZIP CODS'/�p D <br /> i19. <br /> OWNEA TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY <br /> ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL.AGF,NC'1' [� H.NON-GOVERNMENT <br /> TY(TK)HQ 44 �' - ./ Call the State Bwud of ualiiati Fuel Tex Division, +-� <br /> _ Eq ort, um,ifthefe are question, <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER <br /> ❑ 4.TANK OPERATOR <br /> i� 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Requiredf PPa61tc Agencres OniyJ <br /> 466. <br /> Ip <br /> CERTIFICATION: I certif that the information raided herein is true accurate <br /> APPLICANT SIGNARE and is full cora liance with Ic al requirements. <br /> TU <br /> DATE /v au. p HONE� <br /> APPLICANT NAME(prim) H�ibA= o 426 APPLICANT Tr,, /f L�/ Q0 <br /> / <br /> UPCF UST-A Rev.(12/2111417).1/2 K$"os <br /> www.¢¢ldocs.arg ., <br />