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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT [2-3.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check oae item only) '3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE $ 9.TRANSFER PERMIT <br /> L FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' 1 FACILITY ID# L] <br /> (Agency Use Only) <br /> BUSINESS NAME(Savo ss EACH=MAMZ urr DBA-r>�Bum„ As) 3. <br /> I+kpH <br /> vt <br /> BUSINESS E A s 1 C'f C A -1'( � C� �f�`C A: 04. <br /> FACILITY TYPE I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 405, <br /> 3.FARM 4.PROCESSOR ❑ 6.OTHER Trust lands: ❑Yes Wo <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407• PHONE 408 <br /> MAILING ADDRESS409 <br /> Z 3S-�? kcL&k I 4n) k dl <br /> CITY 410. 1 STATE 411. ZIP CODE 412. <br /> r4oz'' CA jfZ Q'� <br /> III. TANK OPERATOR,INFORMATION <br /> TANK OPERATOR NAME 428-1. 1 PHONE 429 <br /> NI'IYA b CH TOY lya-UYe .J11� M`� NC-u �erj (.zoq } 14(Z 7(-67s <br /> MAILING ADDRESS / 428.3 <br /> CITY 428.4 STATE 428-5 1 ZIP CODE 428-6 <br /> cA- J'F-2 fi� <br /> IV. TANK OWNER INFORMATION <br /> TANK.OWNER NAME 414. PHONE 415- <br /> MAILING ADDRESS 416. <br /> CITY 417- 1 STATE 418. ZIP CODE 419. <br /> CA-- Jrzos_ <br /> OWNER TYPE; ❑ 4.LOCAL AGENCY/DIST."RICT ❑ 5.COUNTY AGENCY 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY @B.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ Q¢ 1 () � Call the State Board of Equalization,Fuel Tax Division,if there are questions. Q 1 <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to [:11.FACILITY OWNER 4.TANK OPERATOR 423 <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 igformation provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURF DATE 424. 1 PHONE425. <br /> qt 2_ 7•rJv <br /> APPLICANT NAME(print) 42b- APPLICANT TITLE 427 <br /> 111 1-1 A } ICN -r 0 V e 6 - <br /> UPCF UST-A Rev.(12/2047) <br />