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AAJ <br /> UNIFIED PROGRAM CONSOLIDATED FORM 3/2% i/tot% <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ I.NEW PERMIT la3.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE aoo. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# <br /> (Agency Use Only) <br /> BU SS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. <br /> C 1.1 lylea-T <br /> BUSINESS SM ADDRESS 103. CITY 104. <br /> FACILITY TYPE 0,1.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? ❑Yes ❑No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407• 1 PHONE 411. <br /> MAILING ADDRESS 409. <br /> CITY 4M 1 STATE 411. 1 ZIPCODE 412. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4211-1, PHONE 428-2 <br /> MAILING ADDRESS 426-3 <br /> CITY 428-4 1 STATE 4228-5 ZIP CODE 42" <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAMEala. PHONE 415. <br /> o J <br /> MAILING ADDRESS 416. <br /> CITY 417. 1 STATE 418. 1 ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY ago. <br /> ❑ 7.FEDERAL AGENCY f.�8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> a TY(TK)HQ 44- 19 ILICJ ILI 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: 41�r I.FACILITY OWNER 4.TANK OPERATOR 423 <br /> 3.TANK OWNER 5.FACILITY OPERATOR <br /> e <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) ' <br /> VII.APPLICANT SIGNATURE F._ <br /> CERTIFICATION: I certify that the injorm4tion provided herein is true,accurate,and in full com fiance with legal requirements. <br /> APPLICANT SIGNATURE DATE03 5 E <br /> l j 424. PHONE� � S ( 1 azs. <br /> APPLICANT NAME(print) 426• APPLICAN TITLE .427 <br /> r�f2L- Si��'i� �J(�✓1J�12 <br /> UPCF UST-A Rev.(1212007) <br /> s C 0 M to, <br />