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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> YPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE a00 <br /> (Check one item only) IDS RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> Wmww� L FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404- FACILITY ID# _ <br /> a (Agency Use OntyJ <br /> BUSINESS NAME(S..u FACa.1TY NA xDBA—Doing eusineu AQ 3 <br /> A . I <br /> BUSINESS TE DRESS 103. CITY 109 <br /> V L,42 . 1_0c✓ellv I I'GGV <br /> FACILI' 'YPE 1.MOTOR VEHICLE FUELING El 2.FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or <Os. <br /> `� ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes 19-90 <br /> nklow", It. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 403 PHONE 408. <br /> q &30 - al (o <br /> ING DRESS m9. <br /> 7 ,,, le_[( <br /> CITY 410. STATE 431. ZIP CODE 412_ <br /> { C CG g53->(o <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 1-F ( 428-1, PHONE 4282 <br /> roc IA`,l/lQ'4I (aoco ) 836 - 321 <br /> MAILING ADDRESS 428-3 <br /> Lo we l/ &ZBa li <br /> JTY 4264 1 STATE 428-5 ZIP CODE 4284 <br /> c� Cy CCi 53719 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> r , ( ) g30- 3a Ico <br /> MAILING ADD S 416. <br /> Q 7 D ✓P,�u e <br /> CITY 417. STATE 419. ZIPCODE / 419. <br /> TI'a c a y 5 3 to <br /> OWNER TYPE: R4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK) HQ 44- 1 1Call 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: Erl.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406 <br /> Ca Se Goo o�t1 - s ac- Sv erl.. vq Z4 6( 31ftes—' <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> (CANT SIGNATURE DATE 424, PHONE 425. <br /> 10 q 3-3D-3 a)& <br /> PLI AM NAME(print) 422. APPLICANT TITLE 422 <br /> Flee w. r � ll <br /> UPCF UST-A Rev.(1212007) <br />