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L 11� <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> \, OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br /> (One form per facility) <br /> ,ro <br /> TYPE OF ACTION ❑ I�eJEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Chet err irc......40 }} RENEWAL PERMIT ❑ b.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> 1. <br /> TO7A 'UMBER OF USTS ATF ILI__ FACILITY ID r _T=7 <br /> _ <br /> '3 J (Agrac�Use It I I <br /> 3 <br /> BUSINESS NAME(5mne as Faccilln�N n,e or DBA-DO61g 8ustnrss Asl <br /> /.SS C7w� taFIS <br /> CITY • la <br /> BUSINESS SITE ADDRESS�..� <br /> ,oi <br /> FACILITY TYPE .MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION acility located on I dian rvalion or <br /> 3.FARM 4.PROCESSOR b.OTHER ands? ❑ I.Yes No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY O R NVAE J01 PHONE <br /> Xr ��.�.¢� 37,7- X38 t <br /> MAILING ' RS• RCK (S2_:S,_ <br /> CITY Gv +I STATE 411 ZIP CODE 41' <br /> L-o C 4 • <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4'st PHONE 452' <br /> 4t8 3 <br /> MAILING ADDRESS <br /> CITY STATE 4A3 ZIP CODE 42"r <br /> IV. TANK O R INFORMATION <br /> TANK OWNER NAME 4N. PHONE 415. <br /> 416, <br /> MAILING ADDRESS <br /> CITY <br /> 4n. STATE ue. ZIP CODE u9 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT [:3 j.,POUNTY AGENCY ❑ 6.STATE AGENCY 4as. <br /> C] 7.FEDERAL AGENCY 02111,NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 4n. <br /> Cell the Sute Board oYEqualiutioq Fuel Tu Division.if there are questions <br /> VI.PERMIT HOLDER INFORMATION <br /> 4?l. <br /> Issue Permit and send legal ratifications e1d mailings Io: .FACILITY OWNER ❑ 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(RePdredJor Arblic Agencies Only)lei <br /> VII.APPLICANT SIGNATURE <br /> (CATION: I e t at the lIrrnation rovided herein is true,accurate od full compliance with I al requirement <br /> A 1 TUR DATE/O , /0 4'4- PHON 4=5 <br /> Z�._ <br /> APPLICA AME(Print) �� 4'-4• APPLICANT T Lb ---- U-7, 427 <br /> mss' UPCF UST-A Rev.02/20071•D2 www.onidocs.ovg � <br /> f <br />