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RECEIVED <br /> UNIFIED PROGRAM CONSOLIDATED FORM FEB 14 2014 <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMALrf <br /> N1 <br /> TYPE OF ACTION 0 L NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Check one item only) ❑ 3,RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY °04 FACILITY ID# <br /> (Agency Use Only) p ' <br /> BUSINESS NAME(s.,ne FacalTv nnngor nea-oemy a,amess a 3. <br /> 't EaS b=oo Qr <br /> BUSINE S SITE DRESS 103. CITY <br /> FACILITY TYPE I.MOTOR VEHICLE FUELING [12.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 4o5. <br /> ❑ 3.FARM 4.PROCESSOR [:] 6.OTHER Trust lands? ❑Yes 49 No <br /> e II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NA 40¢ PHONE409. <br /> A L�1✓ <br /> Zoe( <br /> 0 7 <br /> MAIL NG ADDRES 409. <br /> P-3 aseM e c- <br /> CITY 4'0 1 STATE C ZIPCODE 412, <br /> e cv: C A 1 qs:7 3 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPE TOR NAME 429-1. PHONE 428.2 <br /> Z k��� (zo ) a'11 - zO ( <br /> MAILING ADDRESS 429-3 <br /> 3 q 2 3 S <br /> zZC4z9r g4IP q 4z6t4cqC� �� % j-z / Z <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 45. <br /> ( zo9 ) %F-q?-73 <br /> MAILI G ADDRESS ` 416. <br /> yGS � <br /> CITY 437. STATE 419. ZIP CODE 419. <br /> 0 C� A S 33 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 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 10: ❑ I.FACILITY OWNER 45 4.TANK OPERATOR <br /> 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406, <br /> VII. APPLICANT SIGNATURE <br /> CE TIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> AP CA IGN RE DATE 424. PHONE 425. <br /> 2- /Y- IL( 2� a7i - 2o/ <br /> 1 T N (print) J 426. APPLICANT TITLE 427 <br /> k'�Qr Dom' .ve✓ <br /> UPCF UST-A Rev.(12/2007) <br />