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NOW rt/ UNIFIED PROGRAM CONSOLIDATED FORM APR 0 6 20105 UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-FACILITY INFORMATION µ (One form per facility) TYPE OF ACTION ❑ 1.NEW PERMIT ❑ S.CHANGE OF INFORMATION400. ❑ 7.PERMANENT FACILITY CLOSURE (Check one item only) 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# 1 (Agency Use Only} BUSINESS NAME(Same as FACILrrY NAME or DRA-Doing Business As) BUSINESS SITE ADDRESS 103. CITY. 104. yl g°t l,J. GV1nr�er L'X <SANA-\� ) (A FACILITY TYPE 1.MOTOR VEHICLE FUELING © 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes No Il. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 4117. PHONE 408. �e yo$ tilt) - y o i 1 MAILING ADDRESS P aoy lOt7Z0 rOSP.V i�+Z �ri� CITY \\ Oto. STATE 411 ZIP CODE 412. s a^ JU5 q5 Z`9 III. TANK OPERATOR INFORMATION TANK OPERATOR NAME 42x-1. PHONE 428-2 aCKP- MAILING ADDRESS 429-3 CITY 428-4 STATE aza-s ZIP CODE 428-6 IV. TANK OWNER INFORMATION TANK OWNER NAME 414. PHONE 415. MAILING ADDRESS 416. CITY 417. STATE 419. ZIP CODE 419. OWNER TYPE: ❑ 4.LOCAL AGENCYlDISTRTCT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- Call the State Hoard of Equalization,Fuel Tax Division,if there are questions. 42,_ VI. PERMIT HOLDER INFORMATION Issue permit and send legal notifications and mailings to: X 1.FACILITY OWNER ❑ 4.TANK OPERATOR 421 ❑ 3.TANK OWNER ❑ 5,FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. VII.APPLICANT SIGNATURE CERTIFICATION: I certify that the information provided herein is true accurate,and in full compliance with legal re uirements. APPLICANT GNATURE i DATE Lf } 414. PHONE 425, APPLICANT NAME(prat 426. - APPLICANT TITLE 427 UPCF UST-A Rev.(12/2047)