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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 ❑ I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 41S. <br /> (Ch«k one nem only) 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY4oa_ FACILITY ID k )^ �7 _ f' t <br /> 3 (Agency Use Only) /r Y/ y V <br /> BUSINESS NAME(Soot ss FACILITY NAME vr DBA-Doing B.,.As) 3_ <br /> Ahlwix Smslyc- <br /> BUSINESS SITE ADDRESS 1o3. CITY IN. <br /> 12 may, MA.47AA - 44 . 953� <br /> FACILITY TYPE Rk 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or nos. <br /> 3.FARM 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407_ PHONE nos. <br /> SAA "In_�IA I N '09ppe, L 6'G _ xo' US43 - 172-Y <br /> MAILING ADDRESS <br /> 2 <br /> CITY 410. STATE 411. ZIP CODE ala. <br /> M C4 9s13o4� <br /> HL TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAMF 4284. PHONE 4242 <br /> 5AN JVA LL114 ROPA71 ( ) <br /> MAILING ADDRESSp 428-3 <br /> azs a 7C 2- 5-19 g <br /> CITY STATE ZIP CODE a sa <br /> /✓I/3iJ/ �' S33 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> MAILING ADDRFCe 416, <br /> P•P, 2 —2—CITY 417 1 STATE 41s. ZIP CODE 419. <br /> C 533 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY azo. <br /> ❑ 7.FEDERAL AGENCY g 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 0 LJ Z 0 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 4zs <br /> 3.TANK OWNER - FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406_ <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I ert4 that the inform ided herein is true,accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNAT i DATE azo. PHONE azs,i r� z -112. <br /> APPLICANT NAME War) 426. APPLICANT TITLE 427 <br /> III!)" <br /> Ama <br /> J� <br /> UPCF UST-A Rev.(1712007) /'1 <br />