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UNIFIED PROGRAM CONSOLIDATED FORM( � <br /> UNDERGROUND STORAGE TANK � ' l PERMIT -�,d►� g <br /> OPERATING PERT APPLICATION-FACILITY INF TION 1 / <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 <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION IZ-d 2 3 Q <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# /� _ 121317- TI(Agency Use Only) r�1 _ <br /> BUSINESS NAME(Satre as FACMM NAME or DBA-Doing Business As) 3. <br /> BUSINESS SITE ADDRESS "r Aj LJt J Y r V-1 1 03. 104, <br /> LA L1 o kl <br /> FACILITY TYPE &KI.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or aos. <br /> 3.FARM 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ❑No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. 1 PHONE 408. <br /> V - • /� ,v, r1., � 1 c1 SVS ab� �`: � �3� L <br /> MAILING ADDRESS 409. <br /> CITY 410. STA/T�E 411. ZIP CODE 412. <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> MAILING ADDRESS 428-3 <br /> CITY 4284 j STATE 428-5 ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> !`rnwe v),< LA ,�e j Z ( ) <br /> MAILING ADDRESS 416. <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> F EQUALIZATIO UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 L, 1 Cj 7 c? 3 1 M S Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421' <br /> IV VI.PE HOLDER INFORMATION <br /> ue permit and send legal notifications and mailings to: 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> �/ !J ❑ 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. PHONE 425. <br /> :)- <br /> APPLICANT <br /> APPLICANT NAME(print) 426- APPLICANT TITLE 427 <br /> UPCF UST-A Rev.(12/2007) <br />