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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> �✓ (One fi0rm per facility) <br /> TYPE OF ACTION L NEW PERMIT ❑ S.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Chock one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# <br /> (Agency Use Only) FTT I <br /> 1 BUSINESS NAME(Saone u FACQ.UY NAME or DBA-Doing Business As) 3. <br /> SA N 0-CA Q Ul N I^G= ►o N-/9 L- _ryQ?ANS!T' 005 i.?)�T` <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> JF_7 _5 7-b C KT-6 4 <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 605 <br /> 3.FARM 4.PROCESSOR 6.OTHER Trust lands? ❑Yes No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME W r L p T-_=L_L K R E:li L..._ 407 PHONE 409. <br /> :5^ 1q <br /> MAILING ADDRESS 409. <br /> /-�zl fw, wBI✓ f VIF-z <br /> CITY 410. STATE41 t ZIP CODE 412. <br /> :S 7-o C V,-T-0 CGJ4 I q <br /> HL TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME ��p 1`oo�gF- to L 1, 428-1. PHONE 429-2 <br /> SCK To A G2 LZ AL <br /> MAILING ADDRESS 429-3 <br /> Com, 429.4 STATE 429-5 ZIP CODE 429-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 1 PHONE 415. <br /> SA nC 0A v Jr N h'' -JQ (2 c } 6S- X145 <br /> MAILING ADDRESS416. <br /> . vv 0 E 1� A V <br /> CITY 417. STATE DE 419. <br /> s T'o C K 7-o rl C 419. ZIP CO <br /> 19 QTS o5' <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT P9 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_ Call the State Board of Equalization,Fuel Taut Division,if there am questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> issue permit and send legal notifications and mailings to: ❑ I.FACILITY OWNER 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406, <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> K,R s.m X=-7 L.._. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate,and in full com fiance with legal requirements. <br /> APPLICANT NATURE. DATE O 424 PHONE 4u. <br /> - 1'4 ltd 323 3155` <br /> APPLICANT NAME(print) 426- APPLICANT TITLE C O hLT A Li�V R 427 <br /> C?A N x' <br /> UPCF UST-A Rev.(12/2007) <br />