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UNIFIED PROGRAM CONSOLIDATED FORM 'l n <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 ❑ T 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# _ _ t. <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. <br /> ^4 sT. A R co 4 In PI'S -CJ /l EN rE'RPa�a c"� IAJC <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 110 5, /V S7. In gt4-r&'-Aq C-A, 9533-?- <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? ❑Yes ❑No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407, PHONE 408. <br /> 1E-5 KD(_ ENTe-rePR--IJ6-S 4GG 7?C- 3 <br /> MAILING ADDRESS 409. <br /> 477L ;3"N E'S 1-to <br /> CITY 410 STATE 411. ZIP CODE 412. <br /> F12em7 9y5-3 C <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> .r5 KS m�,N sT• �4R�o s�a> (5/0 ) <br /> MAILING ADDRESS 428-3 <br /> 1050 5. /7,4iN 5-r.. <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> C-A • 95 3 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME �C' 414. PHONE 415. <br /> JSKS �Nr�RPR�S�S m'AIN sTRR=r 4ge 8,25- 6 F9`/ <br /> MAILING ADDRESS 416. <br /> 6:� aARnrES LN <br /> CITY 417. 1 STATE 418. ZIP CODE 419, <br /> t=R9MoAuT cA 9YS3G <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- 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 /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify at the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE 121 <br /> K4 DATE ^3 r Q 424. PHONE 425. <br /> 209 SZS 678 <br /> APPLICANT NAME(print) 426 APPLICANT TITLE 427 <br /> ..lpSf3�/2 cHA DD,4 �R1c �R SEGR�Ts+-RY <br /> UPCF UST-A Rev.(12/2007) <br />