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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> r'YPE OF ACTION L NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400' <br /> (Check one item oNy) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY FACILITY ID# <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(Somas FACILITY NAME orDBA-Doing Business As) 3. <br /> SA nl, TyA Q Ul S: ,G; 12 N-/91-- T_)?, NS"!r 015"1 1�-3- <br /> BUSINESS SITE ADDRESS 103, CITY 104. <br /> wf_rBE'R A v -577>CKT67\- <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION a0s. Is the facility located on Indian Reservation or 405' <br /> 19 <br /> 3.FARM 4.PROCESSOR 6.OTHER Trust lands? ❑Yes No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME W M p I=-L_.L R l.._ 407• PHONE 406• <br /> S V LtA PISERM- (;ZO2 <br /> MAILING ADDRESS 409. <br /> ,iF"7, 1 p-=. Wim. BAR AVS <br /> CITY 410.rATE 411. 1 ZIP CODE 412. <br /> �TC7CK-TDr� GR <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME ��p � 1 L_ 429-1. PHONE 429-2 <br /> _5ATO RTIC (,Zv ) F�"? " Cr o� <br /> MAILING ADDRESS 428-3 <br /> CLI., 429-4 STATE aza-s ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414, PHONE 415. <br /> 5A ks 0A Q v PN 12'T"JZ:) ( c ) /4 6S- Ll 4S <br /> 416. <br /> MAILING ADDRESS <br /> V <br /> q2 I �. 1n/F_ 1B E� /4. <br /> 417. STATE 419. ZIP CODE 419. <br /> CITY � 1I.S' 0's- <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- <br /> 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: E] 1.FACILITY OWNER X 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 /> �CERTJFICATION: I certi that the information rovWed herein is tru accurat and In full com fiance with le al re uirements. 4zsANT SIGNATURE. DATE PHONE <br /> ��� ^ )`-f j� c> 323 3lSS- <br /> 426. APPLICANTTTTLE 427 <br /> �� APPLICANT NAME(print) T� C p�7W'Q <br /> rJ A h! P�- <br /> UPCF UST-A Rev.(12/2007) <br />