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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK r. <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (O ig h <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE Boa' <br /> (Check m"'--'y) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY EACH=CLOSURE ❑ 9.TRANSFER PERMIT SANJOA,-Aj!,q t30UN Y <br /> I. FACILITY INFORMATION H= Erpr"u-P`4hE1 <br /> TOTAL NUMBER OF USTs AT FACILITY '°'. F q _jolojo - 171g I 191 1 <br /> FACILITY ID# <br /> ' (49-1y UM 0*) <br /> Bus S NAME( l\v� ^n N «u`-r•`ooins ✓v,rea�� ). <br /> BUSINESS SITE ADDRESS�-C 103 CITY toy <br /> `a O `4- 0• <br /> FACILITY TYPE .MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION. °03' Is the facility located on d' Reservation or 405' <br /> 3.FARM 4.PROCESSOR 6.OTHER Trust lands? ❑Yes o <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4n2I PHONE 406_ <br /> F-ra.nlGeNe Eocobar 2p� $f �1-3� 2to <br /> MAILING ADDRESS 409. <br /> `-�o <br /> CITY 410. 1 STATE 411 1 ZIPCODE a2. <br /> Mane « <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 42 1 1 PHONE 42 2 <br /> L-,eti e cZo`a $ 3 ;7-2-(a <br /> MAILING ADDRESS 428-3 <br /> -3 a �U, eo L-Q-- <br /> CITY h- . � Com— 4za4 1 STATE �- aze-s ZIp COpS�� sieb <br /> W✓` IV. TANK OWNER INFORMATION Qty <br /> TANK OWNER NAME 414. PHONE 4s. <br /> Fr6i NbeNe- USS e b a v^ 0-0ci $ `I 3 <br /> MAILING ADDRESS 416. <br /> CITY . 437, 1 STATE� 419. Ze CODE�3 � � 43v. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> 6 ❑ 7.FEDERAL AGENCY ❑ S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 10 1 q- 4- 0 1 L7 3 1 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 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 4a_ <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate and in full compliance with Legal requirements. <br /> APPLICA T SIGNATURE DATE 424 PHONE 425. <br /> APPLICANT NAME(print) GQ 426 APPLIC TITLEA 4n <br /> n <br /> UYI:F Uh1-A Nev.II]1LW7) <br />