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NIFIED PROGRAM CONSOLIDATED FOR R E C E I D <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION( fnpav fgil�y)20 1 <br /> auo. <br /> TYPE OF ACTION 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Check one mon Oely) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT ENVIRONMENTAL I EEALTH <br /> L FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY FACILITY ID k <br /> O N�L' ((gamy Use only) s <br /> BUSII4FSS NAME(s wFncttrrYNAhtE roar-DM90�.tr Mme\ � S� <br /> MOW-14 �\OL61P— C -1��� 10. CITY ion <br /> BUSINESS SPIE ADURFSb i�\ <br /> cj' �zi- 0QC42ASb�\iS 151 ao,. <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION Is the facility I on Indian on or <br /> 3.FARM 4.PROCESSOR 6.OTHER <br /> Trust lands? [I Yes �No <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME + PHONE 4os. <br /> M e MA S g Ilp 3 SSP - 5 l30 �. <br /> MAILING ADDRE35 <br /> CITY y <br /> S' �1 410. S ATE 4u. ZIPCODE 412. <br /> M. TANK OPERATOR INFORMATION <br /> ae•1. PHONE aze-z <br /> TANK OPERATOR NAME <br /> NO PAIL 628 3 <br /> MAILINGADD S <br /> cr <br /> 4zs< STATE <br /> 4n 5 21P CODE 62" <br /> cITY Sg 3 3 <br /> S�CRnM 4n.� <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414, PHONE 418. <br /> o R�c N\ S.T (gCCo ) SSQq . S l36 416. <br /> MAILING D S <br /> 1A �i�lc Cfi <br /> CITY 417. STATE +ts ZIP CODE 919. <br /> OWNER TYPE: [14.LOCAL AGENCY/DISTRICT �❑ 5O.COUNTY AGENCY ❑ 6.STATE AGENCY <br /> azo. <br /> [17.FEDERAL AGENCY >LL NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY HQ 44 0 5 Call the State Board of Equalization,Fuel Tax Division,if there are questions <br /> azt. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ I.FACILITY OWNER [14.TANK OPERATOR 4zz <br /> K3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> ass. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: Ice that the information rovided hereto is sceura and in full Compliance with legal uimments. azs. <br /> PLICANT SIGNATURE p DATE <br /> l(0 3S4�SI 30.x, <br /> PL CAIS'rN (print) +� APPLICANT TITLE <br /> eS <br /> UPCF UST-A Rev.(12CW7) t <br />