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go � <br /> UNIFIED PROGRAM CONSOLIDATED FORM n <br /> UNDERGROUND STORAGE TANK ►lJ�X_ <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per clhty) <br /> TYPE OF ACTION Ej 1.NEW PERMIT CHANGE OF INFORMATION C37.PERMANENT FACILITY CLOSURE 400 <br /> (Check one item only) RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 4-. FACILITY ID 4 <br /> (Agency Use Only) J ! 6 3 <br /> BUSINESS NAME(Same as FACLL=N or DBA— J B mess As) <br /> JZ <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> FACILITY TYPE Qil'FIOTOR VEHICLE FUELING [12.FUEL DISTRIBUTION 403, Is the facility located o dian Reservation or 40 Is <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes 94-W <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408. <br /> MAILING AEFDRESS <br /> CITY 410. STATE 411. ZIP CODE <br /> 11-1 ,,� ' T S 3? <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4-8-1. PH. <br /> MAILING ADDRESS 428-3 <br /> CITY 4284 ST a2s-s ZIP CODE 42" <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME ff 414, 1 PHONE 415. <br /> MAILING ADDRESS / 416, <br /> 91- S- ✓ <br /> CITY _ G 4/ �-'\ <br /> 417. ATE 4 418. ZIP COD a19. <br /> W � e <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY JDJ�8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421- <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 /> CERTIFICATIO : I certift that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANTGNA URE DATE 4'-a PHONE 425 <br /> ZcJ ZEA ! 1 <br /> APPLICANT NAME(print) <br /> 426- APPLICANT TITLE 42' <br /> UPCF UST-A Rev.(12/2007) <br />