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0 • 0 10 <br /> UNIFIED PROGRAM CONSOLIDATED FORM Lla I <br /> UNDERGROUNDSTORAGETANK I <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION El 1.NEW PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 4D0' <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 404. FACILITY ID# [,,- _ jj� ;4 t' <br /> (Agency Use Only) ) Ft, ) l0' <br /> BUSINESS NAME(Sunt as FACn.ttY NAME or DBA-Doing Business As) 3. <br /> V <br /> BUSINESS SITE ADD SS 103. CITY 104. <br /> 1(40 L_A 3Ttj"P R-D i',ATtf fit° <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 /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> _ C1fAyL_S00blQ Ool <br /> MAILING ADDRESS 409. <br /> i Lfb " f P-Z <br /> CITY 41 U' STATE 411. ZIP CODE 412. <br /> "- HR-af CA 95-336 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 PHONE 428-2 <br /> NL)7- 7UE CA9 zee_ <br /> MAILING ADDRESS 423-3 <br /> l qo L�1Tfl�Poi� 1�f.3` <br /> CITY 4284 1 STATE 423.5 ZIP CODE 47M <br /> LA7'NkD+0 CA q�33n <br /> W. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 413. <br /> 514AM50D0lt.3 f (Zc�1 )9f3Z-s <br /> MAILING ADDRESS 415. <br /> l q6 LAT-1440f r2 <br /> CITY W. j STATE 418. ZIP CODE 419. <br /> L.AVH"f GA 95-3.76 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 423. <br /> ❑ 7.FEDERAL AGENCY 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> T}('JK)HQ 44_ 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 423 <br /> ❑ 3.TANK OWNER 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I cerdfy that the infor sti©n provided herein is true accurate,and in full compliance with legal re uirements. <br /> APPLICANT.SIGNAIURE- DATE 424. PHONE 4T5. <br /> APPLICANT NAME(Ffnnt) 476 APPLICANT TITLE 427 <br /> IiCJ�L`l,4Yva .SI.+QD6 GdvuTGot-t-�-+L� <br /> UPCF UST-A Rev.(17!2007) <br />