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T <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK 1/ ] <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One forth per facility) <br /> TYPE OF A;only) <br /> ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400' <br /> (Check one itet4 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' 1 FACILITY ID# <br /> '1 (Agency Use Only) l <br /> BUSINESS NAME(Same as FACB.rrY NAME or DBA-Doing Business As) 3. <br /> W <br /> esuIF kA 05 s <br /> BUSINESS SITE ADDRESS 103. CITY104. <br /> C Q <br /> 3�0 �v . w es l._ n <br /> FACILITY TYPE 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- PHONE 408. <br /> 3-m 66- I W <br /> MAILING ADDRESS 409. <br /> CITY 410. 1 STATE . 411. ZIP CODE 412. <br /> S�oc o C,1 1 9 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1, PHONE 428-2 <br /> n (�� 6'2_3`i'6 <br /> MAILING ADDRESS Box <br /> �,� '91 <br /> 428'3 <br /> �. <br /> CP1Y 4284 1 STATE 428-5 ZIP CODE 42M <br /> a3 a i C R 9 © l <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415, <br /> MAILING ADDRESS 1 416. <br /> P-© . <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> �} C 9', o <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- © a y 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 /> f 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 OW information pFpvided herein is true accurate,and in fuli compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424• PHONE 425. <br /> . l x a.-S' mO fol %B3 <br /> APPLICANT NAME(print) 426• APPLICANT TIME 427 <br /> LOME UST-A Rev.(1712007) <br />