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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> f,� 400. <br /> TYPE OF ACTION [IL NEW PERMIT E] 5.CHANGE OF INFORMATION pl 7.PERMANENT FACILITY CLOSURE <br /> (Check one itan aoly) C-13.RENEWAL,PERMIT [16.TEMPORARY FACILITY CLOSURE ( ❑`9.TRANSFER PERMIT <br /> t >p <br /> I. r <br /> TOT NUMBER OF USTs AT FACILITY FACILITY ID N L — <br /> aOSP��� , (A"mey Use Only) 0.:' <br /> BUSINESS NAME(S®e a FAcn.rrr masa oan-Danegy�p'"®a.i = <br /> 5 JIn1 L�OU/ILT ffcJMA- /Ce�S ta. <br /> BUS ESS SITE AD S toa. CITY <br /> /4.:�- . STo�ton/ <br /> 4a1 <br /> FACILITY TYPE ❑ L MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION all. Ie the facility located on IndeResavadon.m <br /> Trust lands? El Yea allo <br /> ❑ 3.FARM 4.PROCESSOR 6.OTHER _ <br /> " kRTY OWNERINFORMATION <br /> 407. PHONE 408.. - <br /> PROPERTY OWNER NAME <br /> yds cXJ4lNf"' 4m. <br /> MAI/I.I�N A♦♦Dd /'l!' <br /> RESScc ••,, <br /> / /a <br /> r , - 41I. ZIP CODE 412. <br /> CITY vOto. STATE <br /> 09 <br /> TANKOPEKATORNAME 4v-1• PHONE <br /> msa <br /> MAILING ADDRESS <br /> CITY 4294 STATE ZIP CODE 42" <br /> - <br /> ,7T,--,V. TANK OWNER INFORbiATI.,', i�P <br /> 414 PHONE 415 <br /> TANKOWNER NAME <br /> tj 416 <br /> RES <br /> /�!• A mi .r ( 419. <br /> 4n. STATE Ota Z�CODR�^� <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICf S.COUNTY AGENCY ❑ <br /> 6.STATE AGENCY 4m' <br /> ❑ 7.FEDERAL AGENCY ❑ 8 NON-GOVERNMENT <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tats Division,if there are queanotu. <br /> Issue permit and send legal notifications and matings to: I.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ S,FACILITY OPERATOR <br /> 400. <br /> VISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> 'rK t G 2�'�I �CORRr. <br /> VII.APPLICe� <br /> CERTIFICATION: I certillthat the information rovided herein is tru accurate and in full com liaoce PHONEaI require 2 ments, 425 <br /> APPLICANT SIGNATURE DATE <br /> ¢6B-7-0 <br /> --4M APPLICANTTITLE <br /> APPLICANTNAME(print) 4n <br /> �iabr�e. ares 'D` r�c- a� <br /> UPCF UST-A Rev.(1212007) <br />