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d <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK U ��IV I� <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION N <br /> (One form per facility) <br /> TYPE OF ACTION ❑ I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400' <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# _ t' <br /> Z 1 (Agency Use Only) _ <br /> BUSINESS NAME(Same asFACB,mN or DBA-Doin Bs_in�As) -y� 3. <br /> t...) AAs) <br /> 5 <br /> BUSINESS SITE ADDRESS e-- 103. CITY 104. <br /> 5 f� <br /> FACILITY TYPE E)44.MOTOR VEHICLE FUELINa ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on In 'an Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes o <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. 1 PHONrE + 408. <br /> \j 17Jh V <br /> MAILING ADINRESS /"� 409. <br /> C ` 410. STATE 411. ZIP CODE 412. <br /> CA,- ` J <br /> . TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME428-1. PHONE_ 428-2 <br /> 428-3 <br /> CITY 4284 1 STATE 428-5 1 ZIP CODE 42M <br /> q . <br /> IV. TAN OWNER INFORMATION <br /> TANK OWNUAME ^ 14. PHONEJ l 415. <br /> MAILING ADDr <br /> 1\/� J 416. <br /> Y��,^ •� � 417. 1 STATE als. ZIP CODE alv. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISfRICT ❑ 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- r Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421' <br /> I.PERMIT HO DER INFORMATION <br /> Issue permit and d legal no ifications and mailings to: ---64-FACILITY 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 cc the information provided herein is true,accurate and iq full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE f 424. p 425. <br /> 6 <br /> APP NT NAME(print) 426. APPLICANT T E 427 <br /> � G v <br /> UPCF UST-A Rev.(12/2007) <br />