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IZ14o <br /> `'6NIFIED PROGRAM CONSOLIDATED FO <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (Oa form Per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Check one imm only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF UST.AT FACILITY 4w _ t <br /> FACILITY m N <br /> (Agency Use Only) <br /> 3. <br /> BUSINESS NAME(s®er FwcO.[ry NAAff o<uun-Doaaarrra n,) <br /> lONT/9//VE4C C37e;O TION' /VDD �/V L1FDk'it/OfI <br /> BUSINES SITE ADDRESS 103 CITY 100 <br /> 14 �. Vt c frF moo. 661 <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION b3- Is the facility located on In^dia�n cservation or <br /> 445. <br /> 3.FARM 173 4.PROCESSOR 6.OTHER Trust lands? ❑Yes LeNo <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Derr CnN7771N co�v,� nonr X09 333- 8038 <br /> 4os. <br /> MAILING ADDRESS <br /> /I/00 1-f 1// c7-VX ROAD <br /> CITY STAiEOtt. ZIP CODE 412. <br /> 1 06 / GA 49 , S 0 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME '" PHONE PHONE 4ze-2 <br /> DIRT CONTf�/NeW co,Po��o� (09 ) 333-&)90 <br /> MAILING ADDRESS 428-3 <br /> I q00 �. bl< c7-z)g koogv <br /> CITYQ I G 4284 STATE 4ze-s ZIP CODE �� 42" <br /> Lo TT 9 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME ata. PHONE 415. <br /> YW-T CPAJ7—A/NE7z A) (2-0q) <br /> MAII.ING RESS a1s_ <br /> �M C. c�rz P- <br /> CITY ) Q ^ Iv. STATE 418. ZIP CODE �Q 419. <br /> ti 'J <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY g-8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44_ Call the State Board of Equalization,Fuel Tint Division,if there are questions. 021' <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: GKI.FACILITY OWNER ❑ 4.TANK OPERATOR 4� <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certiry that the information provided herein is true,accurate and in fulj compliance with legal req uirements, <br /> APPLIC S ATURE r-- DATE 021 PHONE 4zs. <br /> --533-9090 CAM NAME(print) az6 APPLICANT 7 427 <br /> ori E z > <br /> UPCF UST-A Rev.(1212007) �E^� ,t-1 ci�"ij <br /> c <br /> r 5 <br />