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1CT-w <br /> f UNIFIED PROGRAM CONSOLIDATED FO <br /> UNDERGROUND STORAGE TANK nll� <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 On. <br /> (Check ova item only) via RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ,$C 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 401' FACILITY ID <br /> (Agency Use On(yJ <br /> BUSINESSNAME(s�urACRI1YNArdeo,DBA-Ddngeiei A4) <br /> lf- t(A- ks I- CrAS <br /> 82314-9 lx/afe� gal Sf�kM9l C/F Q (SITE ADDRESS -ZQ�(^ a,. S�eelr M. <br /> FACI.rrY TYPE gl.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 901 Is the facility located on Indian Reservation or 4a5. <br /> El 3.FARM Q 4.PROCESSOR 0 6.OTHER I Treat RN, <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4a'!. PHONE 408. <br /> Nor/+ aicy THY 11(2uye(Y 468 91.z _�o77 <br /> MAILING ADDRESS 409. <br /> CITY Ota I STATE 411. ZIPCODE412. <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME428-1. PHONE 428-2 <br /> fl!IyA B;cH 7-1f >1NGuyey TIMMY ri6�J�eh (z0q ) 4i(2- 7,raZ <br /> MAILING ADDRESS 428.3 <br /> 2 3SQ IrWeR too !a- <br /> CITY 4284 STATE 4284ZIP CODE 42" <br /> 5l/otA h C A- y,r-z d,1 <br /> IV. TANK OWNERINFORMATION <br /> TANK OWNER NAME 414. 1 PHONE 415. <br /> fit /VA- bi'ck T+fy ftauyeN ( 408 ) 9/2 - &77 <br /> MAILINGADDRESS 416. <br /> z 3a ,Y/a feR-4a-o R <br /> CITY917. STATE 418. ZIP CODE 419. <br /> Sbrk �m cA. q r za,s' <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY Wi.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TIC)HQ 44- () Z 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 mailings to: ❑ 1.FACILITY OWNER 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTTON,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the i ormatioB provided herein Is Irae,aceyM and in full compliance whh legal requirentents. <br /> APPLICANT SIGNATURE DATE 424. PHONE <br /> APPLICANT NAME(print) 426. APPLICANITIPLE 421 <br /> n ( NA- 8I cf/ TN 4-UYeN 6,LW1n-,,(t2 <br /> .- <br /> UPCF UST-A Rev.(12/2007) C, completed <br />