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5Z • I 1�k 7Il crsslu <br /> t UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form par facility) <br /> TYPE OF ACTION 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> I(Chmkmeucmonly) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L FACILITY INFORMATIO .35 <br /> TOTAL NUMBER OF USTs AT FACILITY FACIL71'Y ID A 9 t. I <br /> a �i rls P Ure 4) <br /> BUSINESS NAME(Same 4s FMffMN"`a armBA-Dm4aiiisr Ae 2. <br /> M • `z� te�� m.� - S� <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> lc)5-� Lo. �' 2e \is � ai <br /> FACILITY TYPE Cl 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 903" Is the facility located on Indian Reservation or <br /> 3.FARM 4.PROCESSOR 6.OTHER Trost lands? ❑Yes .?g No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTYOWNERNAME 4111. I PHONE 40a <br /> M ' C <br /> MAILING ADD S 409. <br /> cl <br /> CITY 410. S ATE 411. ZIP CODE 411 <br /> -S i'cG�26��4 b 9S,e -3 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME < qu <br /> 42&1. PHONE a <br /> N"1 C m i iC c I (P ) - 1 0 <br /> MATLINGADD S 42&3 <br /> Cl l 2 <br /> STATE �-5 ZIP CODE 4zr� <br /> Hr S vw n.e. 4za4 5g 3 3 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME r" gyp- 4t4. PILONE 415. <br /> MAILING DD Sm6 <br /> • . <br /> CITY 417. 1 STATE 4111 ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 620- <br /> 0 7.FEDERAL AGENCY )94 NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK .HQ 44- Q 3- Call the State Board of Equalization,Feel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and madiogs to: ❑ I.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> $K3.TANK OWNER ❑ 5.FACILTTYOPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Publie Agencies Only) 406. <br /> VIL APPLICANT SIGNATURE <br /> CERTMCATION: I cerffy that the information provided herein is true,accurate,and in PoI ownChance with I requirements. <br /> PLIC ANT SIGNA a[n} � DATE q24. PHONE 425. <br /> k,3-- ;-`Uig v• 'tae ri y-s f so <br /> PJL CAI NAME(print) 4211 1 APPLICANT TITLE 4n <br /> UPCF UST-A Rev.(12200.1) <br />