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UNHr(ED PROGRAM CONSOLIDATED FORM ftN <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION -FACILITY INFO TI(one form Pa facility) <br /> 5.CFLANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> TYPE OF ACTION L NEW PERNIT [j9.TRANSFER PERMIT <br /> tQrd ary ima mIY1 ❑ :.RENEIA aL PERAIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ <br /> L FACILITY INFORMATION FR-v 77.2T <br /> TOTAL NITOF UST. 1T F a(ILITY «y FACILITY R)= I O 1 — <br /> 3 <br /> BUSINESS NaAIF.S✓nre✓sF✓nim--%✓nr:or SON-f,�-�D,,(o�n¢R+rsnmss.ds'1./ N <br /> ,r a., <br /> mvr , <br /> BUSINESS 9.�� <br /> ma Is the Ea fity Located m Indim Reservation m <br /> FACILITY TY PF �]/1 I.MOTOR VEHICLE RJELING ❑ 2 FUEL DISTR1BLtT10N <br /> Tmsr lardx^ ❑ 1.Acs Na No <br /> 3.FARM 0.PROCESSOR &OTHER <br /> II. PROPERTY OWNER INFORMATION <br /> /�/ p •ny xr PHONE <br /> PROPERTY Z E N i EE \ �J N� • (�l� .J� ."J— 1 O <br /> ALAILING.ADDRESS U36"18 S <br /> 4tn STATE 411 Zip C(NE 412 <br /> `/1�C�� <br /> CITY" <br /> ( <br /> III. TANK OPERATOR INFORMATION <br /> 4�r PHONE <br /> TANK<1pptATOR NAhEE q � o <br /> M.AILWG.ADDRESS <br /> U3b� bST 42s. ZIP CODE = <br /> 4't~+ A'I�E . <br /> E b � <br /> IV. TANK OWNER INFORMATION <br /> ., PHONE <br /> TANKONNFA�NI.ANE OA r - u 13� b <br /> l ,U �� � l— ,tR <br /> XLAHJ NG.ADDRESS GE <br /> Q <br /> Lk 1 1 ns ZIP(-ODE I nr <br /> CITY- 4i STAIE ,� ` ( <br /> q`-1 J y 3� <br /> l/GE 6.STATE AGENCY 4"1 <br /> OWNER TYPE: 1• ` ❑ 4.LOCAL AGENCY/DiSMCT ❑ 5.COUNTY AGENCY L] <br /> ❑ 7.FEDERAL AGENCY SL&NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> GII the Stare Hoard of E9.IvatiM Feel Tu Division iT Ihere are questiom. <br /> TY MW <br /> VL PERMIT HOLDER INFORMATION , <br /> 0.TANF.OPERATOR <br /> m <br /> I e Peso and send kgd eo&katioes and madnrp to. ❑ 3.TENK O R ❑ 5.FACILITY OPERATOR x� <br /> SUPF.RYTSOR OF DUTSICYN.SECHON.UR OFFICE tRegnnrd_frr Puhlra.dgrntr�Onh'! <br /> VII.APPLICANT SIGNATURE <br /> (� C►TION: I rn16 <br /> r tlma duration ovided herein i+1nu,acCvraM,and in fa®Cram 'mn PHONE tdremmis. 4• <br /> SIG I IRE UATE <br /> C;> ®5 ©B R\D 333 Tao <br /> 42+• .APF'LIC'ANT ITILE <br /> aNi'N_`AN (`Rerl) � � L <br /> 11PCF UST-A Rev-(172la'!)-1/2 <br /> www.oeidoaorg <br />