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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK F�9 19 2014 <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> One fomt per faciliTyTT - <br /> a`��"TYPE OF ACTION 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION [17.PERMANENT FACTvir-1 E <br /> (Check one item only) PO 3.RENEWAL PERMIT El 6.TEMPORARY FACILITY CLOSURE El 9.TRANSFER PERMIT j <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' 1 FACH,ITY ID 4 /( _ 0 2>> _ ,IC) I [I C <br /> 4111 ee (Agan T Use Only) J j l/ ll if 6 1 J 1 r r <br /> BUSINESS NAME(Same u FACILITY NAME or DBA-Doing BaNneee M) 3 <br /> oft! IZV-) /Yl Aft T <br /> BUSINESS SITE ADDRESS 103. CITY r 104. <br /> 20 <br /> FACILITY TYPE ILT w,�,'7v� AfEit 204�� GcaJi C� 9rz�4^J ��q'�`f <br /> t.MOTOR VEHICLE FUELING [1 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Respwatma or 405. <br /> E] 3.FARM [14.PROCESSOR [16.OTHER Trust lands? ❑Yes <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME a0z PHONE 408. <br /> pew6q 1 S f fif1SLG/ q16 942/- YOZ <br /> MAILING ADDRESS 409. <br /> (r © S SUUzi4 ,02 , <br /> CITY d10, 1 STATE 411. ZIP CO E 411 <br /> /7IZ -C �'A- ?s ;76 :2- <br /> 111. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> ''110127- <br /> MAILING <br /> 'G/vwf7 MAILING ADDRESS 428-3 <br /> CITY <br /> 4284 STATE 428-5 ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> MAILING ADDRESS 416 <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY .NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 0;?'FACILITY OWNER ❑ 4.TANK OPERATOR 413 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VIL APPLICANT SIGNATURE <br /> CERTEFICATION: I certify that the information provided herein is true,accurate and in full compliance with legal requirements. <br /> APPLICANT IGNATURE DATE 424 PHONE ers. <br /> dz�/S�2o/y 1a7 3697 <br /> APPLI NAME(print) 426. APPLICANT TITLE 4n <br /> V,917 ee-^/ S• ,o _fl �Q Es/ GL JT <br /> UPCF UST-A Rev.(12/2007) <br />