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REenix <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK1 'la: R O 1 2011 <br /> OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br /> (One form per facility) ENVIRONMENTAL HEALT <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400 <br /> (Check one item only) 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# <br /> 7 (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 <br /> MA -E T AIKLD PrMPM - JSKS NG <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 1 10 0 S- M mq ST(REET m cl 533 �- <br /> FACILITY TYPE .(1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Ind'i@n Reservation or 405. <br /> E] 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? E] 1.Yes 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408_ <br /> Jf- KUL ENTERPRISE LLC_ ( 51a ) X96 3 to <br /> MAILING ADDRESS 409. <br /> G i4(LNE. L A--t AC <br /> CITYTATE IP CODE 412. <br /> (ZE rut oN410 SA� all. Z <br /> T C- °t4 S 3 b <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 PHONE 428-2. <br /> M At S -F-e T Kcz hinPm - AkS s E NTEP. 4SES I (2® ) 062-!i- 6-1164- <br /> MAILING ADDRESS 428-3, <br /> IUD 0 . M 1NST-PLEET <br /> CITY 428-x. STATE 428-5. ZIP CODE 428-6. <br /> c a 53-5 -}- <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415 <br /> MAIVA STKEEI MMPI - JS ' S E9j MPRkSts L ( ?-OCT ) c6Ls-- Ion <br /> MAILING ADDRESS 416. <br /> CITY 417 rTATE 418. 1 ZIP CODE 419. <br /> (A A-N-TE CA CA Cl �- <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 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- 10 JL4 16 1 1 S5 I I 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: ❑ 1.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 /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATEi 424. PHONE 425. <br /> �- -1��10 (20q 162S-61�4 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> Ku LbEE P c • say nim rs,- c-lEa <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />