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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> F7 <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 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#Ig <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as FACn.rrY NAMEmDBA-Doing Business As) 3. <br /> 7 t E �-NW C CE <br /> BUSINESS SITE:ADDRESS 103. CITY 104. <br /> ej4b&tcEf Loc Lo �1 <br /> FACILITY TYPE Efl.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 /> (�n � �v <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTYOWNER NAME F f; $ A 0 � a0�. PHONE aog. <br /> a� ) 33y, 3129 <br /> MAILING ADDRESS 409. <br /> iw s eHubi«f- <br /> CITY 410. STATE 411. ZIP CODE o� 412. <br /> HI. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> '4'1�PrL41 fi S ti v L-R ✓✓I����9 C� -R (� > s�a -y9 g <br /> MAILING ADDRESS 42S-3 <br /> 3 2- <br /> CITY `-' STATE 428-5 ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 114 PHONE 415. <br /> `7t> IDH Sr�>`t��(N� - <br /> MAILING ADDRESS 416. <br /> mE <br /> CITY 417. STATE 418. 1 ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY Z 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 411. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 0 1.FACILITY OWNER ❑ 4.TANK OPERATOR 421 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 4 <br /> 116 <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full com fiance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 425. <br /> G► 46� Ib --aG- -,--? ) 334-3i2 <br /> APPLICANT NAME(print) 426_ APPLICANT TITLE 427 <br /> M*WlGit <br /> afvr completed <br /> UPCF UST-A Rev.(12/2007) <br />