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I Ak CFV <br /> U. IED PROGRAM CONSOLIDATED FORM / 4 7wc, <br /> UNDERGROUND STORAGE TANK 1 <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form per Facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT Q 5.CHANGE OF INFORMATION ❑ 7.PER2vIANENT FACILITY CLOSURE 4"' <br /> (Check one item only) ❑ 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> 1. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 41k1 FACILITY ID 4 <br /> (Agency Use Onfv) T — <br /> BUS TNESS NAME(&ma as FAC1LJTY NAME or DBA-Doing Bttstnm As) <br /> AV_tL) S'i'p.'n -.it <br /> BUSINESS SITE ADDRESS 103 CITY <br /> ISO 9. yJ 1%_Set r.L lJJ�41� — - S% 4 i O C- �'�' <br /> 4113. X115, <br /> FACILITY TYPE 14 1.MOTOR VEHICLE FUELING El 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or <br /> ❑ 3 FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? []Yes jNo <br /> j II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME J07 PHONE i"s <br /> MAILING ADDRESS 11Y7 <br /> CITY 4t(', STATE 411 ZIP COLE 412' <br /> 'jUC ILSb+1 e_ <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME u-" PHONE 428'2 <br /> r <br /> MAILING ADDRESS 429'3 <br /> CITY 42 d STATE 42K-5 I ZIP CODE 42%-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 4t4. PHONE 415.. <br /> %ADt VVI- <br /> MAILING ADDRESS 416- <br /> 13>0LQJ L L .0 1 <br /> CITY 417 1 STATE 41S ZIP CODE 419. <br /> SToc.u.Tu,—c L-A <br /> '?_0S <br /> OWNER TYPE: ❑ 4 LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7-FEDERAL AGENCY S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- (o 1 19 1 Call the State Board of Equalization,Fuel Tax Division,ifthere are questions. 421 <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and sena 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: 1 certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT GNATURE DATE 4={ PHONE u'-s <br /> o�J ) G 44 .? <br /> APPLICANT NAME(print) U +2c APPLICANT TITLE 427 <br /> til !fr NG3lZ� /!'I <br /> d LOZZ-99t'-60Z }y61M t3ouaanne� dZV 90 60 LZ Uef <br />