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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 ❑ 1.NEW PERMIT ❑ S.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# 1. <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> a rc S'7`� r RV.,4e 51Q o� s'7�c/i/a.E rrrw� /r„cr /,f/ir ev Alei/,-7 <br /> BUSINESS SITE ADDRESS / 10 CITY 104. <br /> FACILITY TYPE I.MOTOR VEHICLE FUELING 403. 405. <br /> ❑ 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or <br /> El3.FARM El4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes A No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407, PHONE 408. <br /> Cc . S�. 7'C o C / I ( Ssl) 511c1r - <br /> MAILING ADDRESS 40e <br /> B.S_r 14 S/ /!G.7z &I-kr .20c, <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> 7. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME, 428-1, PHONE 428-2 <br /> a//h!r /I.neo �Ge,di ( ./t//q <br /> MAILING ADDRESS 428.3 <br /> CITY 428.4 STATE 42s-s ZIP CODE ata-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME / 414. PHONE 415. <br /> C4 /-h1 <br /> MAILING ADDRESS 416. <br /> g5S' /rt f <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> <rro C 19- <br /> OWNER TYPE: ❑ 4. LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY A6.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- 1 E 1Jo `- /y 1 /-7 1 '-]' I 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: K I.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> < e/I GotAle r <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full com lianCc with Ie al requirements. <br /> APPLICANTSIGNATURE DATE 424. PHONE 425. <br /> 16 <br /> APPLICANT NAME(print) 426, APPLICANTTITLE 427 <br /> UPCF UST-A Rev.(12/2007) <br />