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0 e completed 9 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE Oro. <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 4a. FACILITY ID# 1' <br /> (Agency Use Only) <br /> BUSINESS NAME(SmmnFACB NAMEor DBA-Doingflwi se As) 3. <br /> MAuTR'C-4 4 UtlP G45 <br /> BUSINESS SITE ADDRESS io3. CITY ion. <br /> Sow N f'\pAfjs nn <br /> FACB.FFY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> 3.FARM 4.PROCESSOR [:16.OTHER Trust lands? ❑Yes 1pNo <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4 PHONE 408. <br /> 4ERJ�E S' ffj NI)4l Zv9 7��- L6 1 I <br /> MAILING ADDRESS aos. <br /> 810 N. mvs= fj S� <br /> CITY Q ^to. I STATE 4117FZPCODE / 412. <br /> K ' C4 S '? 6O <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME ^ 428-1. PHONE 429-2 <br /> MAILING ADDRESS 428.3 <br /> CITY 42 STATE 422-5 ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME / ,rO 414. PHONE ms. <br /> MAILING ADDRESS 416. <br /> CITY 417. 1 STATE 415. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT [I S.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY Rt&NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Q14 1 u� I 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: ❑ L FACILITY OWNER E] 4.TANK OPERATOR 423 <br /> .TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE " <br /> CERTIFICATION: 1 certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICAN SIGN TURE DATE 424. 1 PHONE 425_ <br /> to <br /> APPLICANT <br /> 299 r6i=2`I <br /> APPLICANT NAME ring 426. APPLICANT TITLE 422 <br /> UPCF UST-A Rev.(12/2007) <br />