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l ,\ 19. Af <br />UNUUD PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />OPERATING PRNMrT APPLICATION — ]FACILITY INFORMATION <br />(One tbt:n per facility) <br />TYPE OF ACTION ❑ 1. NEW PERMIT . CHANGE OF INFORMATION 0 7. PERMANENT FACILITY CLOSURE <br />(Cba* am Om only) Q 3. RENEWAL PERMIT Q 6. TEMPORARY FACILITY CLOSURE 9. TRANSFER PERMrr <br />L FACU TY INFORMATION <br />TOTAL NUhMER OF USTa AT FACILITY FACILITY IDN <br />3 <br />_ <br />t <br />(Amey Irse 0++13') <br />BUSINESS NAME (So mFAC4JrYNAMvrDBA-Dulg9i bmwA�) <br />BUSINESS SITE ".) 7 w , � a /� �. /�. a- CIl Y tot. <br />F�CILIfY TYPE MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 610.Ia the facility I CMW on Indian Reservation oir 403. <br />i� 3. FARM 4. n2g95M Q 6.OTHER Trwl ltmds7 ❑Yee mo <br />IL. PKOP.ERTY OWNM INFORMATION <br />PROPERTY OWNER NAME <br />c r PHONE <br />14- J1 �~\ � � 1.961 <br />crrY 410. STATE + ,• z� CODE � 411 <br />UL TANK:OPERATOR INFORMATION <br />TANK OPERATORNANIE4�1. PHONE <br />MAILING ADDRI <br />Crit' l42&4 STATE�� 7 ZIP CODE <br />IV: TANK OWNER INFORMATION <br />TANK OWNER NAME 414. PHONE <br />MAILING ADDRESS laol) <br />CITY W 417. STAB J� 41&ZIPCODE <br />OWNER TYPE: 0 4, LOCAL AGENCY/DISTRICT ❑ 5. COUNTY AGENCY ❑ 6. STATE AGENCY <br />❑ 7. FEDERAL AGENCY ❑ S. NON-GOVERNMENT <br />V. BOARD OF EQU,LMATION UST ,ASTORAGE FEE Aopou' i' NUMUM <br />TY (TK) HQ awd the Saw Boof Equallbtion, Fuel Talc DJVW if there ate <br />"��. titteetiona. <br />VI, HOLDER INFORMATION <br />Inm unit and Dead Iftal notifications and atnilinp to: WL FACILITY OWNER ❑ 4. TANX OPERATOR <br />❑ 3. TANK OWNER Q 5. FACILITY OPERATOR <br />SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public ARoncies OD(y) <br />VII. APPLICANT SIGNATURE <br />tify fythaat the-In(ormartiofarovkled hareie tm tm sceprage, and L, ftU <br />✓�7�'�^� <br />DA <br />� <br />UPCF OST -A Rev. (12/2oo7) 1-14 8 - (-/ -?-y <br />410. <br />4,qg <br />