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RECEIVED <br /> UNIFIED PROGRAM CONSOLIDATED FORM �;UG (? 4 2013 <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMA' N1 MT L <br /> IrIM <br /> TYPE OF ACTION ❑ L 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 /> ;L <br /> .... ;1_.FACILITY.INFORIVIATION.:"`-: . <br /> TOTAL NUMBER Of USTs AT FACILITY q04' FACILITY ID# <br /> (Agency use only) 0 <br /> BUSINESS NAME(Same.FACDILY NAME or DBA-Doing Bmsiom AB) 3' <br /> Fs� <br /> BUSINESS SITE AADWS 103. CITY 104• <br /> 3°i �- `1osc.+-��'t� ►`1t7 G ✓''tq.n�' cd� �T�33 <br /> FACILITY TYPE U9 1.MOTOR VEHICLE FUELING C] 2.FUEL DISTRIBUTION 403" Is the facility located on Indian Reservation or 405' <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> H; I'IzOI'ERTY.OWNER <br /> INORMATION'„.- <br /> PROPERTY 64FER NAME 407 PHONE 408. <br /> 111.1.n QO Le Aocr 465 - . '1 Z <br /> MAILING ADDRESS 409. <br /> P- o• 60* I1 -07 <br /> CITY 410• STATE 411. ZIP CODE 412, <br /> S iD C-v,'riD N <br /> TIL TA.NK.O� "Tak INFORMATION.. :::... <br /> TAM OPERATOR NAME 428.1• PRONE 4z8 2 <br /> FA,57 A! IF2.3 -, 3(16 a <br /> MAILING ADDRESS 428.3 <br /> CITY 42" STATE az8 s ZIP CODE 428.6 <br /> - 336 <br /> IV:'TANK OWNER INFORMAx1ON. ::;:• <br /> TANTS OWNER NAME 414, PHONE au. <br /> MAILING ADDRESS 416• <br /> CITY 40. STATE a18. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD'OF'EQUALIZATION UST ST'O)RAGE#EE'ACCOUNT NUMBER. <br /> TX(TI{)HQ 44- Call the State Board of Equalization,fuel Tax Division,if there are questions. 421• <br /> .VI.. <br /> . ' PERMIT HOLDEIt.INk'OItMAT'XON;. ' <br /> Issue permit and send legal notifications and mailings to: ❑ 1,FACILITY OWNER C] 4.TANTS OPERATOR 423 <br /> ❑ 3,TANK OWNER ❑ 5,FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII:'APPLICANT SIGNATURE <br /> CERTEFICATION11 I certify that the information provided herein is true,accurate and in full com liarlce with le al requirements. <br /> APPLICANTSIGN y +� 424. �a 1. ass. <br /> DATE � 17 1 I J PHi� ) � 3,1 K o <br /> APPLICANT (print) 426. APPLICANT TITLS 427 <br /> 1' of Y2 t,c7 Lt- <br /> UPCF UST-A Rev.(17!2007) <br />