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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form Per facility) <br /> TYPE OF ACTION ❑ I NEW PERMIT ® 5 CHANGE OF INFORMATION ❑ 7 PERMANENT FACILITY CLOSURE 4� <br /> R7¢d me nem°"WI ❑ 3 RENEWAL PERMIT ❑ 6 TEMPORARY FACILITY CLOSURE ❑ 9 TRANSFER PERMIT <br /> 1. FACILITY INFORMATION <br /> TOTAL NUMBER OF UST,AT FACILITY 4or FACILITY ID 8 <br /> (Agenry Use Ady) <br /> BUSINESS NAME.Is....r•rntry rvuo>oe4-Ibna B��ti1 <br /> BUSINESS SITE ADDRESS 10J Cm I04 <br /> It 8 S- \ � wt� �1 SZoC�Z� <br /> FACILITY TYPE ® I MOTOR VEHICLE FUELING ❑ 2 FUEL DISTRIBUTION 4m N thefacility located m Indian Reservation m 40S <br /> 3 FARM 4 PROCESSOR 6 OTHER irtul luda? ❑Yes ®No <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4°t PHONE 40s <br /> EAC.F sN��s�M�tV�S iNC— <br /> MAILING ADDRESS <br /> g`1 <br /> CITY n° 1 STATE ��� ZIP CODE 411 <br /> S c"cK v ry 9 S 2A s <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4�1 PHONE 4 2 <br /> MAILING ADDRESS 4ow <br /> X855 S h\ hw� � <br /> Cm ta4 STATE 4�t ZIPCODE 4tas <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME a4 PHONE 415. <br /> e0GN;- <br /> MAILING ADDRESS 416. <br /> Cm 417 1 STATE Ota. ZIP CODE os. <br /> SC Y,—Aso 9 S 2.1 <br /> OWNER TYPE. ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY [16.STATE AGENCY 4m <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- O I: I Call the Shoe Board of Equdiatiart,Fuel Tax Division,if there ate quest osu. 421 <br /> VL PERMIT HOLDER INFORMATION <br /> Luce permit and legal nofkmnmlilto: I.FACILITY OWNER ❑ 4.TANK OPERATOR 4B <br /> ��°" -® 3.TANK OWNER ❑ S.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Req lac Aelmes Only) 40° <br /> VII.APPLICANT SIGNATURE <br /> CER7IFICATI I the idol herein is Ieaea aero Aad NB complimee withkad uiaeeeab. <br /> APPLICANT SIG v DATE /I4 NE <br /> APPLICANT N us APPLICANT TITLE <br /> 13PCF M-A Rev.(I V M7) <br /> Scanned by CarnScanner <br />