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RECEIVE® <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK ENVIRONMENTAL�H���AALTH <br /> OPERATING PERMIT APPLICATION- FACILITY INFO IIUak9EC#AO S <br /> (One form per facility) <br /> TYPE OFA TION ❑ I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Checkane he only) 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NU IBER OF USTs AT FACILITY 404. FACILITY ID# _ _ 1. <br /> ©tjC (Agency Use Only) <br /> BUSINESS I AME(Same as Facility Name or DBA-Doing Business As) 3, <br /> BUSINESS E ITE ADDRESS 103. ClIx 1N. <br /> FACILITY T IPE I.MOTOR VEHICLE FUELING [12.FUEL DISTRIBUTION 403. Is the Facility located on Indian Reservation m 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.0 1 HER I rust lands? ❑ 1.Yes JV 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY DWNER NAME 407. PHONE 408. <br /> T-SZ �iS- S Sh'1 T �eb 1 <br /> MAILING DRESS _ 404. <br /> CITY 410. STATE 41L ZIP CODE 412. <br /> C hlEA1 Y' q4 00 y <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPEF ATOR NAME 428-1, PHONE 42.8-2. <br /> T S 1, 44 913 <br /> MAILING DRESS 4228-3, <br /> 4 Y J=oKc� KO <br /> CITY <br /> 4284, STATE 428-5. ZIP CODE 428-6. <br /> WA jet6oq <br /> IV. TANK OWNER INFORMATION <br /> TANK OWN ER NAME 414. PHONE 415. <br /> i '4 2.I r3 <br /> MAILING DRESS ��� � ^ n � � 416. <br /> CITY 1 1410. STAT 418. ZIPC E /(/,, 412 <br /> en E R L1064 <br /> OWNER TY E: ❑ 4.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)I IQ 44- 10 p Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421' <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit ind send legal notifications and mailings to: I.FACILITY OWNER ❑ 4.TANK OPERATOR 423' <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISC R OF DIVISION,SECTION,OR OFFICE(Required.for Public Agencies Only) 406, <br /> VII.APPLICANT SIGNATURE <br /> CERTIFKATION,,ji,cerfify thatpit information provided herein is true accurate and in full compliance with legal re uirements. <br /> APPLIC SIG DATE 424. PHONE 425. <br /> fo`� 1023 -tFo3'? <br /> PLICAN NAME riot) <br /> 426. A LICANT TITLE 427 <br /> UPCF UST-k Rev.(12/2007)-1/2 www.unidmcs.arg <br />