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1 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facilit- <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Check one item only) 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> I I <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# <br /> TTTI <br /> _ <br /> (Agency Use Only) <br /> BUSINESS NAME(Same.FA'C/ILr Y NAME or DBA-Doing Bus nes,As) <br /> 'Vv Q T 'ho (I f, ��( _l) C <br /> BUSINESS SITE ADDRESS 103. CITY+ <br /> FACILITY TYPE I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility loca on Indian Reservation or 405 <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 47o7. PHONE 411ti <br /> 211c ull� -�e�,.> 'r f� c -� p ���� <br /> MAILING ADDRESS 404 <br /> CITY �, 410 1 STATE __7P CODE 412 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. 1 PHONE 4228-2 <br /> MAILING ADDRESS V 428"3 <br /> CITY 4284 STATE 428-5 I ZIP CODE 428-6 <br /> 953�� <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415 <br /> c . <br /> Rr4 u1 f - S4� A.J < 4 �v (kos ) `336- A-1$2 <br /> MAILING ADDRESS V 416. <br /> I � a/t'i- .� <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> rwLCh 9S30 <br /> OWNER TYPE: 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY -SL,8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 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 /> 4ua <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTI TION: J/certify that the information provided herein is true accurate and in full compliance with legal requirements. <br /> 1 APPL} T SI DATE 424 PHONE 425. <br /> . w C) �- <br /> CANT NAME(print) 426. APPLICANT TME 427 <br /> UPCF UST-A Rev.(12/2007) <br />