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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 INFORMATION400 <br /> (Check one item only) - <br /> ❑ 7.PERMANENT FACILITY CLOSURE <br /> ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ® 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# _ I <br /> Z (Agency Use Only) 2 2 I <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> - �',Ct4 N r Gd <br /> BUSINESS SITE ADDRESS <br /> 103.� k 0 w. �• d$A!,� 61 v,( crrY S-)-o ci, <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING403. <br /> ❑ 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM 4.PROCESSOR 0 6.OTHER Trust lands? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME I 1,D =l -</N 407 PHONE 408. <br /> T� t� 60/� �i iz <br /> MAILING ADDRESS 409 <br /> S-f-t.�.n,. L <br /> CITY S CIL 41Q STATE 411. 1 ZIP CODE 412. <br /> Ci►4 `3 S 2 c <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1_ PHONE 428-2 <br /> MAILING ADDRESS 428-3 <br /> V� kn ►.� - �r I,� L � �r f�k.; of <br /> CITY 4284 STATE 428.5 <br /> G l(4-0 ZIP CODE 42s 6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME y a14. PHONE 415. <br /> N N <br /> MAILING ADDRESS n l 416. <br /> CITY 417. STATED 418. FZIpCODE 419C7 , <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY )T_8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Z S 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: ❑ I.FACILITY OWNER423 <br /> ® 4.TANK OPERATOR <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 com fiance with le al requirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 425 <br /> APPLICANT NAME(print) 426. APPLICANTJITLE . 42 <br /> u�A 3-b A S /�rgN ��e�tct�wi <br /> UPCF UST-A Rev.(12/2007) " <br />