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'y <br /> UNIFIED PROGRAM CONSOLIDATED FORM pp 1 <br /> UNDERGROUND STORAGE TANK �l U !D� <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION lam' <br /> (One form per facility) <br /> TYPE O;ACTION �I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400'(Check oy) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# _ l <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as�ACHM NAME or D Doing B ' As) 3' <br /> j e i �� v C. XV4 bA t �d �c oK&b,fob <br /> BUSINESS SITE ADDRESSI L <br /> 103 CITY to V) l04 <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION;,, P,all ' <br /> [:1403. Is the facility located on Indian Reservation or 405. <br /> 3.FARM 4.PROCESSOR OTHER 7 y Trust lands? Yes ❑No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAthlf 407- PHONE 408. <br /> MAILING ADDRESS 409. <br /> CITY 410• 1 STATE 411. ZIP CODE �y 412• <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2t1 <br /> MAILING ADORE/SS�j 428-3 <br /> a28'1 STATE 428-3 ZIP CO°�,sazs428-6CITY ��_ ` al U <br /> '!�40 c' <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME // 414. PHONE, 1 / 415. <br /> MAILING ADDRESS l 1 416. <br /> CITY / 417. 1 STATE/ 418. ZIP CODE // 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420• <br /> ❑ 7.FEDERAL AGENCY 218.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 <br /> 423 <br /> 2-3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I cern th_4t Ow information provided herein is true accurate,and in full compliance with legal requirements. <br /> a <br /> APPLICANT SIGNATURE DATE ta. PHONE 425.✓ � � � A Q� <br /> APPLICANT NAME ( 426• APPLICANT TITLE 427 <br /> 01 <br /> UPCF UST-A Rev.(12/2007) <br />