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EU <br /> _ M^' o <br /> UNIFIED PROGRAM CONSOLIDATED FORM ENVIRO <br /> UNDERGROUND STORAGE TANK y'1� ■4 N �I <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMA'46AD AI ^ <br /> (One form MWP <br /> TYPE OF ACTION O I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ T PERMANENT FACILITY CLOSURE <a <br /> (CFa<a om n.ody) 0 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY FACILITY ID 4 t <br /> (Ag-,y Ura Only) <br /> Ah1E(G�°bP iCnIIY t <br /> "Tr <br /> eaa�Wl Aas <br /> BUSINESS SITE ADDRESS Ilos C[TY 11 Ia. <br /> O - G. -'?OcQeTom.L <br /> FACILITY TYPE MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION aas' Ia Ne Facility located on ReaervOrion ur Ias <br /> ❑ 3.FARM 4.PROCESSOR 0 6.OTHER True lands? Yes o <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME W I PHONE IL <br /> FVA NLr2 Ne Ezco ba r- <br /> MAILING ADDRESS IW <br /> CRY a'° STATE 411. ZIP CODE as <br /> Maur f� c0. G �t 5 a-6 (e <br /> IIL TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME <br /> 4]b. PHONE <br /> -F V 10 u L aP e- 5i ��4..1 3 -7-" <br /> MAILING ADDRESS / Itl] <br /> a �osu 1� <br /> CITY p 1x1-1 STATE Ix&S ZIP C[)DE— a <br /> �l4,4 Ole Cti_ I e-.1 G CS S 3 <br /> W. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. 1 PHONE 1'5. <br /> -FC4 wf eN'e BSc, b a v' (2nd) 8 `I-312 <br /> MAILING ADDRESS 116 <br /> • D SQ n�-A 7�p1-� <br /> CRY AAi'v`4 alt ST 2Je ala ZIP COJ(E�3 3 `Y ara. <br /> sr s •�iia ((�- `G�� <br /> OWNER TYPE' ❑ 4.LOCAL AGENCYIDISTRICT ❑ S.COUNTY AGENCY ❑ 6.STATE AGENCY tlq <br /> 0 [3 7.FEDERAL AGENCY O I.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)14Q44- Call.the Score Board of E9ual ixation,Fuel Tax DIVIS Ian,if there are questi6m. art <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit end send Iegel notifications and mailings m. 1 FACILITY OWNER [1 4.TANK OPERATOR <br /> Q 3.TANK OWNER ❑ 3.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I corfify that the information pmvided hmin is Ime accurate and in fall compliance with legal rc uircmeata. <br /> APPLIC SIGNATURE L DATE (2Oq CD <br /> APPLICANT NAME.(print) AFFMC T TIIL <br /> UPCF UST-A Rev.0=04)7) <br /> AL <br /> EHNV �oN TE"T <br />