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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK CO <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION /`❑ 1.NEW PERMIT ❑5.CHANGE OF INFORMATION [17.PERMANENT FACILITY CLOSURE 4m' <br /> (Check one item only) qr3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE X 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' 1 FACILITY ID N _ I JZ <br /> (Agency Use Only) <br /> BUSINESS NAME(see.FAcnm NAS or DBA-Doing Bim) 1. <br /> i+- l(A Asl- 0 5 <br /> BUSINESS 2 3'X-v Wq_jE iev R cl S J&dc/w 4 C tt Q r16J^ os. cITY s 4c o. <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or 40 <br /> 3.FARM El 4.PROCESSOR Q 6.OTHER Trust lands? ❑Yea ❑No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 40. PHONE 408. <br /> Hit-tr - Bkfc -rHy rN'liYe(Y lFoSl 412 -�0T7 <br /> MAILING ADDRESS 40. <br /> z 3lS) ik'tle/z l" m G/ <br /> CITY 410. 1 STATE 411. ZIP CODE 412. <br /> sf k far- C-A- q,r i 0'f <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME °28-1. PHONE 428-2 <br /> Pf 1(YA- 6 CH rkY lvGUY¢y TIMMY rib-1�ert (209 ) !,<(Z - 7d-0 v <br /> MAILING ADDRESS 4283 <br /> 4 3 s"Q "eR <br /> CITY 428-4 1 STATE 428-5 ZIP CODE 42M <br /> 5klc� fnel- e)il %"r.2 6'j <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414, PHONE 415. <br /> rf t'/JA- bl'CK Tff`/ rt adYe,N ( hOY ) q/�z _ &7 <br /> MAILINGADDRESS 416. <br /> z 3a �Y/a feR Cao Q <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> 5koL f" I eA- q.rrz� a - <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT r❑�/5.COUNTY AGENCY Ji 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY Wit.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: ❑ 1.FACILITY OWNER 4.TANK OPERATOR 4Z <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is tru accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE -44 <br /> 424. PHONE 425. <br /> nim a�� 6//P/09 2.0 iI62 -7rov <br /> APPLICANT NAME(print) 4$ APPLICANT TITLE 427 <br /> N I PYA 1 CN TH 4-uYeN 6L/Um�2 <br /> UPCF UST-A Rev.(1212007) <br />