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L--4FIED PROGRAM CONSOLIDATED FOR1�. " ,�351 <br /> UNDERGROUND STORAGE TANK /'� Dc%'.�OPERATING PERMIT APPLICATION-FACILITY INFORMATIONo3(One form p <br /> TYPE OF ACTION 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT 6.TEMPORARY FACILITY CLOSURE <br /> ❑ ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION Q 7, <br /> TOTAL NUMBER OF USTs AT FACILITY 404 FACILITY ID# _ _ [_�241. 1 <br /> 3 (Agency Use Only) 19t� <br /> BUSINESS NAME(Same as FACILITY NANIE or DBA-Doing Business As) 3. <br /> 5 A f-,L 07-Oi4 Q L) N 9 E7 Gi 10/d-/9 ` 7-RAt4 S-1 T' b 15-7-A K:7- <br /> BUSINESS SITE ADDRESS 103. <br /> cS 104_ <br /> TTb(Z K 5-N- <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME w µ0 ` K R REa: L- 407. PHONE 408 <br /> S L L.. VlSi o t'>5 -- L,►S_ <br /> MAILING ADDRESS 409. <br /> CITY 410. STATE d 1 1 ZIP CODE 412. <br /> S'-o c tic.-r'o4 GA C3 s <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME JS f?A d P41F-1' 1`4 L 1 428-1. 1 PHONE 428-2 <br /> SA K To ) Ll 6 x. <br /> MAILING ADDRESS 428-3 <br /> ,.,&>e49 fr-. M Y,%?-r LJF- Ste, <br /> CITY 428-4 STATE 428-5 1 ZIP CODE 428-6 <br /> Coq- <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414, PHONE 415. <br /> SA hL OrOA 0 V k N R-r JQ ( o ) /4 bS- 4 Q5- <br /> MAILING ADDRESS 416. <br /> CITY a1z STATE 418. ZIP CODE 419. <br /> s To e L< -r-o N. clog) QTS c7S <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ;4 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 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI. PERMIT HOLDER INFORMATION <br /> 423 <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE_ DATE ata_ PHONE 425. <br /> c,}Q�, 'SE --10-1 3ic� 32 7-3)SS- <br /> 426. APPLICANT TITLE a'`7 <br /> APPLICANT NAME(print) C o rLTJqia C17-DR <br /> V A tit F)F- R-ro,-Al <br /> UPCF UST-A Rev.(12/2007) <br />