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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (one form per Iwility) <br /> TYPE OF ACTION ❑ I.NEW PERMIT ❑ S.CHANGE OF INFORMATION )!C7.PERMANENT FACILITY CLOSURE 100. <br /> (Ch` .it..1y) ❑ 3.RENEWAL PERMIT [16.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> L FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 4a1' FACILITY IDN Ir- /� � <br /> (Agency Use O4) i•1 — O O — 3 <br /> BUSINESS NAM E(s aFACRRV NAhteor DSA-u41nae,mmn A.) s. <br /> C4 lirom I S3`t fr 99 510. -rr,eXA. trJG✓4 F/mer /B/i,+to Aeil'/ <br /> BUSINESS SITE ADDRESS / t0d <br /> CfIY ia. <br /> .F. / sS 4 Olid t 7'fd n <br /> FACILITY TYPE UT I.MOTOR VEHICLE FUELING [12.FUEL DISTRIBUTION Is the facility located on Indian Reservation or 401 <br /> r-13.FARM 4.PROCESSOR 6.OTHER Tnut lands? ❑Yes A No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME p 407. PHONE 40L <br /> CA ll- gg S417(eO?C C-011 fOf,1 J4 (Is-set) y S-- L J 7p <br /> MAILING ADDRESS 40 <br /> 8S-f� /y S¢ree� v r d r o70O <br /> CITY +1a STATE +11 ZIP CODE 411 <br /> �4'r.ro <br /> 6105L <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 422-1. PHONE 4M2 <br /> arrner !ilse <br /> MAILING ADDRESS +acs <br /> CfTY - 42" 1 STATE 422-5 ZIP CODE +sea <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME - - +t4. PHONE 415. <br /> MAILING ADDRESS 412 <br /> ss <br /> CITY Ota STATE Ota ZIPCODE 412. <br /> fd/10 C AL <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ^6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 ,E1.x1C11,f1A1 —r1 Call the State Board ofFquali.tion,Fuel Tax Division,ifthere are,questions. 421' <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: I.FACILITY OWNER [14.TANK OPERATOR 4U <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 4M. <br /> < <n (50 <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate,and in full compliance with legal re uirements. <br /> APPLI NTS GNATLRE DATE 42+ PHONE 4u. <br /> "— iv 4/6 9S17-s <br /> APPLICAN//T NAME(prini) 4sa A/P�PLICANTTITLE 427 <br /> •43t/� /y, < l� /1 Md@` e-row / it 1)0,42 7R <br /> UPCF UST-A Rev.(IL2007) <br />