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0 <br /> Viz, <br /> IFI <br /> UNED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION400. <br /> (Check one item only) ❑ 7.PERMANENT FACILITY CLOSURE <br /> ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 41. FACILITY ID# <br /> ._� (Agency Use Only) <br /> BUSINESS NAME(SarnemFACU-r1YN or DBA-Doin�Busi��As) g <br /> 1 <br /> ` <br /> BUSINESS S EACDDRl-z 103. CITY ioa. <br /> JJ w 1� r <br /> FACILITY TYPE E�4.MOTOR VEHICLE FUELIN403' 405. <br /> ❑ 2.FUEL DISTRIBUTION Is the facility located on In an Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes o <br /> U. PROPERTY OWNER INFORMATION <br /> PROPERTYOWNE�NV t COY 407. PHO f aos. <br /> ` <br /> MAILINGG ADAIRESS �1~ }lam 1 409. <br /> Oto. STATE a11. ZIP CODE au. <br /> I. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> MAILING ADD r � � � �I 426-3 <br /> CITY428-4 STATE 428-5 ZIP CODE I 428-6 <br /> S t� <br /> IV. TANIO OWNER INFORMATION <br /> TANK OWNER AME ala. PHONE 415. <br /> MAILING AD S <br /> G � 476. <br /> e 4` 417 1 STATE 418, ZIP CODE / 419. <br /> OWNER TYPE: El4.LOCAL AGENCY/DISfaICT El5.COUNTY AGENCY El6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> / - <br /> TY(TK)HQ 44- r, �� '� Call the State Board of Equalization,Fuel Tax Division,if there are questions. 4�1' <br /> 1 Q I.PERMIT HOLDER INFORMATION <br /> Mi , <br /> Issue permit and sed legal no ifications and mailings to: ILfIY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I cehWy if the information provided herein is true,accurate,and iq full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424, p 425 <br /> c� t�'%) <br /> � <br /> APP fcICAtNT (print) �/1 � 4'-6. APPLICANTT���,E< _ w <br /> I` ME +., �,. 427 <br /> V <br /> UPCF UST-A Rev.(12/2007) <br /> F <br />