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... completed ..4. �cl ► 3b z <br /> UNIFIED PROGRAM CONSOLIDATED FORM �ll 7,,�] <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form <br /> 400. <br /> TYPE OF ACTION ❑ 1.NEW PERMIT 5.CHANGE OF INFORMATION [1 7.PERMANENT FACILITY CLOSURE <br /> (Checkone item only) ❑ 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. _ _ t <br /> 3 FACILITY ID q JJ�� <br /> (Agency Use Only) R'1 lJ V <br /> 3. <br /> BUSIN/E�SSN�AnM�pTl mFA/jjM NA MDOA-DuinsBwi AS) cac `T <br /> Vr"V "1 A v las. CITY <br /> BUSINESS SITE ADDRESS �/ lm <br /> W 1 D vx e. Ave, n f-eC A <br /> 4a5. <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or 405. <br /> 3.FARM ❑ 4.PROCESSOR [16.OTHER <br /> Trust lands? ❑YesNo <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4% PHONE 406' <br /> sSao9. <br /> MAILING ADD �rZ `t n EOv ',,,k co\T3-Tf�/1 <br /> fI{h •14 lw ato. STATE /1 °u. ZIP CODE_ J J / � °tz. <br /> CITY ' (At <br /> T� <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> S <br /> 42&3 <br /> MAILING ADDRESS <br /> CITY 4281 STATE axa-s Z[P CODE °28b <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME �_,n414. PHONE 415. <br /> b. <br /> MAILING ADDRESS <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4zo. <br /> ❑ 7.FEDERAL AGENCY ❑ S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> Ty('TK)HQ 44_ Call the State Board of Equalization,Fuel Tax Division,if there are questions. 431' <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: V.1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> aa5. <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 true accurate and in full compliance with legal requirentebts. <br /> APPLICANT SIGNATURE DATE 4z4 I PHONE t. 4 . <br /> �e <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 439 <br /> t <br /> E <br /> UPCF UST-A Rev.(1212007) <br /> L._ t <br />