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4 � <br /> 17 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 ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 4M <br /> (Check one item only) ® 3.RENEWAL.PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAI.NUMBER OF USTs AT FACILITY 404 FACILITY ID# 1' <br /> 4 (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> Ni 0 NNI O1 MA(ZT CosiP . ( UNION 76) <br /> BUSINESS SITE PDRESS 103 CITY 104 <br /> 2s 7 5 S. t��i i E P05s �--D . T�Z�cJ <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? ❑ 1.Yes ❑ 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 404. <br /> Gi9-R Pn, eL z3c - 6 z ► 1 <br /> MAILING ADDRESS 409. <br /> 3\o RNT 17tJ' v <br /> CITY 41D, I STATE 411• ZIP CODE 412 <br /> MoUN i�� t� NovSl= CA QS 3 � <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 429-1- PHONE 428-2. <br /> AR P N)INI J2- (2-0q > X635 - -7777 <br /> MAILING ADDRESS aza a. <br /> 255 -75 S. i r2swN Pis , . <br /> CITY 4234 1 STATE 429-5. ZIP CODE 428.6. <br /> Cry 95376 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414, PHONE 415 <br /> G� v A PATFL <br /> MAILING ADDRESS 416. <br /> to N No � Avr <br /> CITY an. 1 STATE ala. ZIP CODE 419. <br /> MouN7A� �tcvS� Cts q 539 1 <br /> OWNER TYPE: ❑ 4.IDCAL AGENCYIDISTRICT ❑ 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- 4 5 1 C) q l Call the State Board of Equalization,Fuel Tax Division,if there arc questions. 421 <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ® 4.TANK OPERATO 42b' <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPE <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) "`""` ' 406• <br /> a <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirementL <br /> APPLICANT SIGNATURE / DATE 424. 1 PHONE 425. <br /> f)felL 9 Zo a 3 777 <br /> APPLICANT NAME(print) 426 APPLICANT T1TLh an <br /> lR PATEL -Tg E AsU2ft� <br /> UPCF UST-A Rev.(17!2007)-1/2 www.unldocsorg <br />