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~ <br /> 10/87/2006 03:47 #2164 g.002 /002 <br /> � <br /> UNIFIED PROGRAM CONSOLIDATED FORM V0 <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> El (One fbrm per facility) <br /> TYPE OF ACTION 0 1 NEW PERMIT S.CHANGE OF INFORMATION 0 7.PERMANENT FACILITY CLOSuRF 400. <br /> 01 MPORAR _lTy CLOSURE [3 9.TRANSFER PL-'khffT <br /> TOTAL NUMBER OF 11,STs AT I-ACILITY FAcTLrry TD <br /> BUSINFSS SITE ADDRF�l CITY 104. <br /> FACILrI'Y TYPE )ff ],MOTOR V�HIC'J,E FURLING 2.FUEL DIS§TRIBUI ION 40. <br /> Q) Is the facility located on Indian RcSgrvation or 405' <br /> Trust <br /> 4.PROCFqSOR 6.OTHER Trusi lands? 1.Yes 2.No <br /> _MSS 407 PHONE 401k <br /> MAILING ADDRFZS a i! <br /> C177 Lo(A- 1 410. 411. ZIP CqOF,::� 412, <br /> ATIO <br /> K OPERATOR NAME 428�11- 423.7. <br /> 4283. <br /> MAILING ADDRESS <br /> \acA UZ), KaetMNIC4� Lj­v <br /> TANK OWNER NAME <br /> 414. PHONE 411 <br /> MATI.TNG ADDRESS 414. <br /> VV <br /> CrI 417. STATE 41& ZIP COJ�4 419. <br /> OWNFR TYPE� 4.LOCAL AGENCY/DISTRICT 5.COUNTY AGENCY El 6.STATE AGENCY 4M. <br /> 7.FEDE-RAL AGENCY _120S.NON-bOVERNNffiNT <br /> 777777777777777-777 <br /> FEE AC <br /> Ty(TK)H,Q 44- 161 w b 1.112-19 1 Call the State Board of Equalization,Fuel T&\Division,if there arc questions. 421, <br /> Issue permit and send lcgal notifications and mailinSs to: FACILITY OWNER 4.TANK OPERATOR 4U. <br /> El 3.TANK OWNFX 5.FACILITY OPERAI-OR <br /> UR <br /> CERTIFICATION: Wervify tbAtjhe ifi�MA*on Rrovided beftin is true,accurate,and in full compliance with k*21%illaments. <br /> 19,11 <br /> E 3 <br />� <br />� <br /> U <br /> K <br />