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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK �g <br /> OPERATING PERMIT APPLICATION- FACILITY INFORMATION �� <br /> (One form per facility) -n� �4�AI-TH <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION [17.PERMANENT FACILITY`--C'LOSURE 400 <br /> (Check one item only) 1X3.RENEWAL PERMIT 6.TEMPORARY FACILITY CLOSURE <br /> ❑ ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# ( t <br /> S (Agency Use Only) A Q 6 <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> M A%VA STREFT AkC-0 AtA PM f S KS INC.- <br /> BUSINESS <br /> NGBUSINESS SITE ADDRESS 103. CITY 104. <br /> 1 loo s.MAkrA ST9,EeT \'SAANTEC-A CA 95 33 <br /> FACILITY TYPE g 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? ❑ 1.Yes 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> r--SKUL LL c. 510 `I 9 6 -3y"1v <br /> MAILING ADDRESS 409, <br /> G-1 $ARNES CANE <br /> CITYSTATE 411. ZIP CODE 412. <br /> � <br /> � EMotAl C- X14 53 b <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2. <br /> MNIN ST t-T A&CO MP -- J& K.S ENTEMPMSES IN ( 1.09) S2-S ~ (o g4 <br /> MAILING ADDRESS 428-3. <br /> Iloo S . MXLN STKE!~ T <br /> CITY 428-4. 1 STATE 428-5. ZIP CODE 428-6. <br /> l\A A-N TE C_A Gh ':Vi S 33 �-- <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> MA tN S'fREE T P&Co Pr MPM -- 3 S V S Eti'[E P ISES 1W. <br /> MAILING ADDRESS ate• <br /> lloo S. MAIN ST E -T <br /> CITY 417. 1 STATE 418_ ZIP CODE 419. <br /> MAIN Tt L/* c.A <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY X8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- p LA $ Call the State Board of Equalization,Fuel Tax Division,if there are questions. 4;1. <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 DATE 424. 1 PHONE 425. <br /> 2- 21 1 ! 2 a 5625 ^6� 4- <br /> APPLICANT NAME(print) 426. APPLICANT fITLE7 427 <br /> Ku L DEQ.P C. M4 <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidoes.org <br />