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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 INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400' <br /> (Chcck oao item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 400' FACILITY ID# _ t' <br /> I !Agency Use Oa1yJ <br /> BUS ESS AMEn 3. <br /> [ e <br /> Ori6Modal <br /> BUSItESS SiSE ADDRESS O 103• C1T0 A 1 104. <br /> frftl <br /> PE ❑ 1.MOTOR VEHICLE FUELING [12.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 40s. <br /> MCI <br /> FACILITY TY <br /> ❑ 3.FARM ❑ 4.PROCESSOR 6.OTHER Trust lands? ❑Yes jgNo <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME q 407 PHONE 408. <br /> Locli� av\o2-ldl(., Imo_ f'<t- A--Zwl <br /> MAILING ADDRESS 409• <br /> X75 �. �I�o�l-� A-✓c <br /> CITY a10• STATE at1• ZIP CODE 412 <br /> j,oia( CA �7�z4a <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 422-1• PHONE 428.2 <br /> Lod[ rn i4�I cZ� ) i <br /> MAILINGADDRESS 4283 <br /> CITY V t 429-4 STATE _ 42s-s ZIP C?16g4o 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> L.O'I. MQtoru�- �-PI� (Z <br /> MAILING ADDRES 416' <br /> X75 &Uk <br /> CITY 411. 1 STATE ata. ZIP COD 419. <br /> mpg( CA SZ4U <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ S.COUNTY AGENCY ❑ 6.STATE AGENCY a20. <br /> ❑ 7.FEDERAL AGENCY M&NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> I <br /> TY(TK)14Q 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421' <br /> VI.PERMIT HOLDER INFORMATION <br /> i� <br /> Issue permit and send legal notifications and mai{ings to: 427 <br /> A 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> ❑ 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 certify that the information provided herein is true accurate,and in full corn Mance with le al re uirements. <br /> APPLICA TS GN9/fURE DATE 974• PHONE 425• <br /> ,���� 2 Z.r o� Z09 554_t'1`�'- <br /> APPLICANT NAME(print) 426• APPLICANT TITLE m <br /> i TAS IL 154d To SCI ui1 Es I�I,A-�1 r ME>�`t- �I YLt=G1' 12 <br /> UPCF UST-A Rev.(12/200' ) <br /> i <br />