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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> [7: <br /> TYPE OF ACTION ❑ 1.NEW PERMIT x 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF JSTs AT FACILITY 404 FACILITY 1 # _ _ t. <br /> 11 (Agency Use Only) <br /> BUS SS NANIE(Same as FACIITrY NAME or DBA-Doing 8Minm As) 3. <br /> LIYlI blf <br /> BUSINESS SITE S to3. - CITY 104• <br /> FACILITY TYPE X 1. TOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on I dian Reservation or 405. <br /> El 3.FARM 4.PROCESSOR 6.OTHER Trust lands? ❑Yes No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. 1 PHONE /&62,'LO8- <br /> 00C <br /> 3q-t ' qJ1 0552. <br /> 409. <br /> MAILING ADDRESS <br /> 1-187c)� <br /> CITY 41!)• STATE 411• ZIP CODE 412 <br /> yyl � <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1• PHONE 4228-2 <br /> MAILING ADDRESS 428-3 <br /> CITY 41-8-4 STAT 4za-s ZIP CODE 428 6 <br /> kck�A �-� <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 24U. <br /> 4ss2,1 i�'`txr (2og ) )_-3q-%k34-7/0q5 z <br /> MAILING ADDRESS 416' <br /> 48go Pca'k Ave. <br /> C <br /> 417, STATE 418. ZIP C�� 419. <br /> MU (;'_ CA <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT D 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY i41 8.NON-GOVERNMENT <br /> V. BOA OF TORAGE FEE AC <br /> TY� K)HQ 44- Call the State Board of Equalization7FueIT77ision,if there are questions. 421' <br /> 423 <br /> Issue permit and send legal notifications and mailings to: ❑ 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 /> CERT C O • tfigt the informatio provided herein is true,accurate,and in full com Hance with legal re uirements. <br /> APPLICDATE G 424 PHONE 425. <br /> 20 (W-ORS 2 <br /> APPLIC aS s��t) �1� 4 6. APPLICANT TITLE D 427 <br /> r e v�r <br /> UPCF UST-A Rev.(12/2007) 00 PF <br />