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& a <br /> 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 4u, <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#: JPJAJ - 10 � 0 �0 � - 11141614� <br /> > (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) , <br /> �MA�tN STP.- LL-C. <br /> BUSINESS SITE ADDRESS 103. CITY 104, <br /> T E OZ p( - <br /> FACILITY TYPE MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or 405. <br /> �1. <br /> 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ L Yes 92.No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. 1 PHONE 408. <br /> JSSQL T 4-P AJ S LL c, ) q 6 - +0 <br /> MAILING ADDRESS 409. <br /> 6L_A-iJ C <br /> CITY 41U' STATE alt. ZIP CODE 412. <br /> '��rno X17 c g 4 s 3 6 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2. <br /> iA A tt ! "[ -?' {� itis ( Z-05 s -6 <br /> MAILING ADDRESS 428-3. <br /> Ilop S . M iN STS 7 <br /> CITY 4284• 1 STATE 428-5. 1 ZIP CODE 428-6. <br /> 10 A N"CL C-P, Cl 5 3 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME ala. PHONE 415. <br /> m - QS C--VtE ISE (-2-0'q ) 0bZ5- b <br /> MAILING ADDRESS LtL a16. <br /> M <br /> CITY 417. 1 STATE 418• 1 ZIP CODE 419. <br /> M pt -( C./r C A CIS 33 -4- <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- 4 513, 1 \ (T 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 /> APPLIC T S ATURE DATE 424. PHONE 425. <br /> 312.0 2a 2S 4-1 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> I-UL c - SHAMA- M M Lim <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidoes.org <br />