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• Ol }0 <br /> l u <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION--FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ L NEW PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 4°°. <br /> (Check one item only) ❑ 3 RENEWAL PERMIT <br /> 6.TEMPORARY FACILITY CLOSURE ❑ 9,TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 40! FACILITY ID# l <br /> (Agency Use(7nly) HAH,010101 -16MI�Tll <br /> BUSINESS NAME(Same esFACtT_TE"yNAMEorDBA—WngBusin As) 3 <br /> I! t1 V V <br /> BUSINESS SITE ADDRESS, 1 / 103. L/ <br /> C 3e <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ❑No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY O R NAME r 5l I 407. PHONE 408, <br /> Y- 9 CSS <br /> MAILING ADDRESS <br /> 409 <br /> CITY � Oto. <br /> STATE alt. ZIPCODE � 412. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR N 421-1P <br /> HONE 428-2 <br /> MAILING DRE <br /> (`? ;5) <br /> ADDRESS-.CCIII �C ♦^•�C��{ L ' I �v I� <br /> CITY 4-'8-3 <br /> 4tJ� 1 42$4 STATE ` '128-5 ZIP CODE v ,� 428-4 <br /> Uf �� <br /> IV. TANK OWNER INFORMATION <br /> TANICtO RNAME _i Ll l 414. ,rPH�O;NE/ JC <br /> II � en- <br /> MAILING <br /> ^ � l qrs. <br /> MAILING ADDRESS 416. <br /> CITY an. STATE 41a. ZIP CODE � .�� qyq, <br /> OWNER TYPE: ❑ 4.&CAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY b"j.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> Ty( K)DQ 4 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> t VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER 4,TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I--- that the information provided herein is true,accurate and in full compliance with legal requirements. <br /> APPLICANT ATURE <br /> DATE I 424. PHONE 4M <br /> APPLICANT NAME(print) 420. APPLI ANT TITLE 427 <br /> `1I <br /> rr/``']]E/�r�>'C ( <br /> UPCF UST-A Rev.(12/2007) <br />