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RECEIVED <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANKj� <br />OPERATING PERMIT APPLICATION -FACILITY INFORMAI; [IRONM <br />ENT <br />One form per o�15�t <br />TYPE OF ACTION 42�,1. NEW PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 7. PERMANENT FACILITY CLOSURE <br />(Check out item only) <br />400 - <br />❑ 3. RENEWAL PERMIT ❑ 6. TEMPORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT <br />I. FACILITY INFORMATION <br />T NUMB�R OF USTs AT FACILITY 404, <br />FACILITY ID # <br />1. <br />�� U ? <br />(Agenty Use Only) <br />USINES AME(Svneu FACIL1TY NAME or DBA- Doing Business As) <br />3 <br />i�� <br />BUSINESS SITE ADDRESS IOI. <br />FACILITY TYPE 1. MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation <br />or 405' <br />3. FARM 1 4. PROCESSOR 6. OTHER Trust lands? ❑ Yes 4jJ4, <br />PROPERTY OWNER NAME nNE <br />4oe. <br />+� <br />MAILING A DRE <br />409 <br />/_ <br />S <br />! 6 <br />CITY 410. STATE 411. <br />ZIP CODE <br />412. <br />T (0I"X21TOR0tj[ <br />TANK NAME 439-1 PHONE <br />429-2 <br />�OPERATOR <br />PAN <br />MAILING ADDRESS <br />/ <br />438-3 <br />CITY 4ze< <br />j <br />STATE 428-5 <br />ZIP CODE <br />429a <br />!� <br />c,"11 <br />S ZC <br />[V. 'I_'-r4N .OWNER INFORM TTON, <br />TANK OWNER NAME 414.PHONE <br />iU 4� C� �U �� �/ ( 2�', - - - <br />415. <br />T <br />MAILIN DD <br />416. <br />CITY _ 417. <br />S G- i2,J <br />STATE 418, <br />ZIP CODE <br />419. <br />G9. <br />t� <br />OWNER TYPE: ❑ 4. LOCAL AGENCY/DISTRICI' ❑ 5. COUNTY AGENCY ❑ 6. STATE AGENCY <br />azo. <br />❑ 7. FEDERAL AGENCY .NON-GOVERNMENT <br />V. BQARD F ftUALIsGSTION `UST STORAGE FEE � C, ",,, TNIWOER <br />TY (TK) HQ44- Call the State Board of Equalization, Fuel Tax Division, if there are questions. <br />421. <br />VYz PERMIT HOLD" INFORMATION <br />Issue Permit and sed legal notifications and mailings to: IQ6. FACILITY OWNER ❑ 4. TANK OPERATOR <br />4" <br />❑ 3. TANK OWNER ❑ 5. FACILITY OPERATOR <br />SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies Only) <br />406. <br />VIL APPLICANT SIGNATURE <br />CERTIFICATION: I certify that the informs ' o'vided herein is <br />true, accurate and in full compliance with legal requirements. <br />APPLICANT SIGNATURE <br />DATE r 4z4. <br />3 /S PHGNE <br />' <br />2 1--3 <br />APPLICANT t 4z <br />�[�� <br />APPLICANT TfILE _ <br />4n <br />�L <br />UPCF UST -A Rev. (12/2007) <br />L <br />