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u � <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION 9 1.NEW PERMIT ❑ S.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400• <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY °� FACILITY ID# _ I <br /> (Agency Use Only) <br /> BUSINESS NAME(Sax as FACHM NAME orDBA-Doing Business As) 37 <br /> 5A nt Td/4 Q U1 N E:Gi 10N-15 L- <br /> BUSINESS SITE ADDRESS M. CITY 104. <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 Iands? ❑Yes 2QNo <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME w M p I=-L,tL_ K.R 407. PHONE 408. <br /> MAILING ADDRESS °pq' <br /> '4�zI a, wr. S3Efz. A V� <br /> CITY 410. ATE 411 ZIP CODE 412. <br /> ST <br /> IIL TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME tia 1%,ojF=' r4 1 1, 428-1. 1 PHONE 428-2 <br /> 5s�K To RT f� (,2v ) " 66 o <br /> MAILING ADDRESS a28-3 <br /> CITY <br /> ; 4281 STATE 428-5 ZIT'CODE 428-6 <br /> Com- <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 1 PHONE 415. <br /> 5A y4 o/9 Q U y N R"T'4-D U o ) 4 bS- 4 49- <br /> ai5. <br /> MAILING ADDRESS <br /> 21 417. STATE 4CODE 419. <br /> cITY� To e 1< -T-o rl 18. ZIP� OS <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT Dd 5.COUNTY AGENCY_ ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ &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 /> Issue pantit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER 4.TANK OPERATOR <br /> az3 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> K,R_x-)=- t!.-. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate,and in full compliance with legal ruirements. <br /> APPLICAN SIGNATURE_ DATE 42a• PHONE °u <br /> `J APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> rJ�h1 P�.T'1�' ►QS''Ohl. CC.?'O R <br /> UPCF UST-A Rev.(12/2007) <br />