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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One Porn]per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT E.5-CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 40D" <br /> (Check oqa it=only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILI'T'Y CLOSURE ❑ 9.TRANSFER PERMIT <br /> -TT <br /> TOTAL ER OF USTs AT FACILITY 4 FACILITY ID# _ t' <br /> (Agency Use 0*) <br /> BUS SNAME(Ss mFACa=NANEm1)BA-DaigBmv=Az) 3• <br /> BUSINESS SrfE ADDRESS 103. CITY 104. <br /> �vs,- ?- Q a- Sok m", X20 <br /> FACILITY TYPE F•I.MOTOR VEHICLE FUELING ❑ ?FUEL DISTRIBUTION 405' 19 the facility located 6n Imian Reaetvation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Tnot lands? [I Yrs M No <br /> PRAPERTY OWNER NAME 407• PHONE 401•" <br /> 1�-�J �( m STs . �-s�-�,•ta� ( �� ) 7 Ydd� . <br /> MAILING ADDRESS 409• <br /> '/S Qom. <br /> CITY 41D. STATE 411. ZIP CODE 417. <br /> iL. : 4 TA7VK'QPF.IZA RI1FbRMATTON 1j .77 <br /> w 't <br /> TANK OPERATOR NAME - a2&1. PITON$ a18.2 <br /> T-�•� `x'3,4- .- Y toss ( 2�) �s�- o Q l � <br /> MAILING ADDRESS 42&3 <br /> 7 411b <br /> CITY 42114 STATE 428-5 ZIP CODE 42M <br /> - ,�=�:TANK,��NERINF'ORMA'TIi¢N•' - _�`,�- _ <br /> TAJOWNERNAME 414. PHONE 415. <br /> -.5-- <br /> 1-w <br /> MAILING <br /> MAILING DRESS 416. <br /> CITY <br /> 417. 1 ST 418. ZIPCODE 419. <br /> TE� <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4• <br /> ❑ 7.FEDERAL AGENCY �9 S.NON-GOVERNMENT <br /> .f .v i r in - _Nw� •�' t i,:. <br /> . ° ..,:;'Y. .$ •s�+�l��n,OF;�Qu�I7A V .�5`,��'�����:��,4 A O� r.4w�a1i1M''CKTE�:�., �, <br /> TY(TK)HQ44- Call the state Board of Equalization,Fuel Tax Division,if there are quesdolls. 421 <br /> VI �R�T HOI.I.IER INFQ�Mt�'T�O1V -_ - . <br /> Issue permit apd send legal notifications and mailiAgs to: ❑ 1.FACILITY OWNER [6 4.TANK OPERATOR 423 <br /> ® 3.TANK OWN&R ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VZL,A.pFI:�GAIVT SIGNE �LTRE <br /> CERTIFICATION: I certify f a rovldcd herein is true accurate,and in full com Hance with sl requirements. <br /> APPLICANT SIGNATURE DATE PHONE 42S• <br /> APPLICANT NAME(print) Q6, APPLICANT TITLE 427 <br /> ! � c <br /> UPCF UST-A Rev.(12/2007) <br /> _. � �t � �-.tun <br /> 6116 'd 80108586H I 'oN Xdd 'HM SS37 HW QOO,d Yid 65 :ZO NOW/6002/20/M <br />