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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION E: <br /> (One forth per facility) <br /> TYPE OF ACTION ❑ I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400' <br /> (Check one item.only) 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> t � EcF <br /> I.IORMA <br /> TOTAL NUMBER OF USTs AT FACILITY 404. T <br /> FACILITY ID# � n`,:�' Q �; 1, <br /> 11 (Agency Use Only) <br /> BUSINESS NAME(Same as FACILM NAME or DHA-Doing Business As) 3 <br /> F- s- N 6.s <br /> BUSINESS SITE ADDRESS 103' CITY 1°4. <br /> l39 6,- YoSet-i* e AO e- ►^1ogNt-C,:k Call 9533 <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING [:12.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 405. <br /> 3 FARM ❑ 4 PROCESSOR ❑ 6 OTHER Trust lands? ❑Yes B No <br /> � qk a tiCnnstiat aux s�r3 v N°E d'r a Y 31 7 r q <br /> .',. � , sI1PROPERTY OWNER:INFORIVIATIO � � � . <br /> .: ._ a �� .... <, t Nva . <br /> PROPERTY OWNER NAME 407. PHONE 608 <br /> JeA H r'>e Pam rZocr 6 5-- 3112-1 <br /> MAILING ADDRESS aos. <br /> P• O• 160A II 7 <br /> CITY 410. STATE a11. ZIP CODE 412. <br /> S ioC'KroN G►1 s �a t <br /> �� '' �.p III TA K O�EI2ATOR QRIIVIATION _fix r�r» <br /> TANK OPERATOR NAME 428-1 PHONE 428-2 <br /> FAs; Al rb (ADI) VX3 -- 6Ll60 <br /> MAILING ADDRESS 42g-3 <br /> 1399 <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> ✓-ACX A k-r r G1} g S 3 36 <br /> TANK;OWNE12INFORIVIA ' Of <br /> F <br /> TANK OWNER NAME 414, PHONE 415. <br /> Sir-• c abo v <br /> MAILING ADDRESS 416. <br /> CITY <br /> 417. STATE 418. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ S.NON-GOVERNMENT <br /> � BOARD OF E IPAIIZATION IIST STORAGE!FEE <br /> 4t•x, <br /> y <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> T7- <br /> ERMTT HOLDER INFORMATION � <br /> .... t<�`•it.,., ..t.. r.'fit $N`1"a f'.i��,'a�A rig v _.ys. .. ..s. Fx,,,.x�ti-,.,: _ x- �x• <br /> Issue permit and send legal notifications and mailings to. 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> 423 <br /> ❑ � � <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406, <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> �f 0- <br /> r_A. _ x Z'ILAPP CANT SIGNATURE #$ <br /> CERTIFICATION I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGN DATE 424. PHONE 425. <br /> S � z1�3 (Zoo) X2.3 -3460 <br /> APPLICANT (print) 426. APPLICANT TITLE 427' <br /> f l <br /> UPCF UST-A Rev.(12/2007) ` ` <br />