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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 ❑ L NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400' <br /> (Check one item only) 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# t <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as FACILr Y NAME or DBA-Doing Business As) 3. <br /> C A L-i' PP5 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> `i ry Pz5'C <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 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 /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> V2_ <br /> MAILING ADDRESS 409. <br /> 1 3 q <br /> CITY 410. STATE 411, ZIP CODE 412. <br /> WTem 6.11 ��5�'3 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE v j r-e 428-2 <br /> MAILING ADDRESS 428-3 <br /> i32 A6q54 SOS-e.4puik <br /> CITY 4284STATE 428-5 1 ZIP CODE 428.6 <br /> OP 4✓le,'-.9 1f;4 ;53�4:�. <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> MAILING ADDRESS 1416. <br /> CITY an. 1 STATE 418. 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 STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- t I q- i, L Call the State Board of Equalization,Fuel Tax Division,if there are questions. - <br /> 1. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 1.FACILITY OWNER ❑ 4.TANK 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 /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 4 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 42 <br /> �✓ A-(iA/�oQ_ . LT NLi2. <br /> UPCF UST-A Rev.(12/2007) '§� <br />