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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-FACILITY INFORMATION (One form per facility) TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400' (Check one item only) 3 RENEWAL.PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF USTs AT FACILITY 'NTFACILITY ID p1' .� I (Agency Use Only) - BUSINESSNAME(suo..mcn N orDBA-Doivs Bisinas As) 3. A-/ .�i�rd( Al o �/lA BUSINESS SITE ADDRESS 103. Cfpy 104. FACR.ITY TYPE �I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 43. Is the facility located on Indian Reservation or 40, 3.FARM 4.PROCESSOR [16.OTHER Trust lands? ❑Yes ❑No H. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407. PHONE 408. -P R fN S"N OV/71 6/ ' 020 -8033- Ova MAILING ADDRESS 409, � rf CITY 410. 1 STATE 411, ZIP CODE 412 ln,�Al7ft CF! 9F 3 7 III. TANK OPERATOR INFORMATION TANK OPERATOR NAME 428-1. PHONE 428-2 MAILING ADDRESS 425.3 CITY 42� STATE 428.5 ZIP CODE 42" A70,41 7/-r-- CA 3 IV. TANK OWNER INFORMATION TANK OWNER NAME 414. PHONE 415. MAILING ADDRESS 416. t�L CITY 417. STATE 418. ZIP CODE 419. IvA l 7�eA c,g 9 3'7 OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. ❑ 7.FEDERAL AGENCY ErS.NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 10 4 Call the State Board of Equalintion,Fuel Tax Division,if them are questions. 42. VI.PERMIT HOLDER INFORMATION Issue permit and send legal notifications and mailings to: ,❑ 11.FACILITY OWNER [1 4.4.TANK OPERATOR 4 iL1 3.TANK OWNER ❑ 5.FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406' VII.APPLICANT SIGNATURE CERTIFICATION: I certify that the Information provided herein is true accurate and in full compliance with legal requirements. APPLICANT SIGNATURE r) I DATE 424. 1 PHONE 425. 4 5'„ !' 04-06 - b APPLICANT NAME(print) 426. APPLICANT TITLE 427 UPCF UST-A Rev.(1212007)