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rS <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK ( ' <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION' <br /> (Ona Conn per facility) <br /> TYPE OF ACTION ❑ L NE W PERMIT .CHANGE OF INFORMATION <br /> (Check one item only) ❑ 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ ? PERMANENT FACILITY CLOSURE 400' <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF�USTs AT FACILITY 404' FACILITY ID# i. <br /> �7 (Agency Use On(y) - 3 <br /> BUSINE$$NAME(���+,+,,,�-u FACB.r1'YN DBA-Doiryl B.ii.As) 3 <br /> BUSINESS SITE ADDRESS � ) CITY'n3. <br /> /� ✓�',:tf eU'l GU _ <br /> FACILITY TYPE 211.MOTOR VEHICLE FUELING 403 405. <br /> ❑ 2.FUEL DISTRIBUTION Is the facility located on Ind' Reservation or <br /> 3.FARM ❑ 4.PROCESSOR 6.OTHER Trust lands? ❑Yes YNo <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTy�.WNER NAME r 3 0 40, PHONE 408 <br /> 4a9. <br /> . <br /> MAILING ADDRESS J,//� 93 �2�f�� <br /> '`� <br /> CITY � aio. <br /> STA 4¢. <br /> 9S'u 5 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4ze-1. PHONE ` 429.2 <br /> MAILING ADDRESS / <br /> 428.3 <br /> CITY 428-0 STATE 4211 <br /> ZIP CODE 42sa <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 4i4. 1 <br /> /PHONE <br /> MAILING ADDRESS <br /> 416. <br /> CITY 419. 1 STATE 4t9. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY <br /> ❑ 7.FEDERAL AGENCY ❑ 6.STATE AGENCY 420. <br /> >5-ZNON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> K <br /> TY(TK)HQ 44- t L [ Call the Stale Board of Equalization,Fuel Tax Division,if(here are questions. 421' <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ;2!4.FACILITY OWNER ❑ 4.TANK OPERATOR 4D <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 4K <br /> VH.APPLICANT SIGNATURE <br /> CERTIFICATIO "that the informadoe rovided herein is[rue accurate,and is full com Rance with 1 al r uiremegty. <br /> APPLICANT SIG ATU ) r t DATE 424, PHONE 425. <br /> APPLIC N n , ` 426. APPL TITL� 427 <br /> Y4C CauvpJ <br /> UPCF UST-A Rev.(1212007) <br />