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UNNIED PROGRArd CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One Iorm per facility) <br /> TYPE OF ACTION © 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ® 7.PERMANENT FACILITY CLOSURE 4z0t <br /> (Check mw ft 1 only) 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> ;... .I. FA;C1LTi'Y AcTx01�. <br /> TOTAL M.TMBFR OF UST-AT FACILITY 404' FACILITYID 11 <br /> 0 (Agzarcy Use Only) <br /> BUSINESS NAME(Stene m FACR i 7 NAM13 oTDDA.Dohs Dolows As) 3. <br /> p �rk1 f PG" <br /> BUSINESS SITE ADDRESS f 103. CITY 104 <br /> FACILITY TYPE I.MOTOR VEHICLE FUELING C32.FUEL DTSTRTBUTION 403. is the facility loyal on Indian Rmmsdon or aw <br /> 3.FARM ❑ 4.PROCESSOR El 6,OTHER Tnmt lands? d Ye- ❑No <br /> IL-: O! .Z T.O O N <br /> ,. . <br /> PROPERTY OWNER NAME an, PHONE 40, <br /> MAILIN DDRESs 409, <br /> 6,0 6LSS YogeAf4fk Ire. <br /> CITY 610, STATE 411. Zip CODE <br /> Itlr 7C ;+DPE Tt?N <br /> TANK OPERATOR NAME —1. PHONE 428-2 <br /> MAILING ADDRESS 428-3 <br /> CTIY 428.4 STATE 428.5 1 7..TP CODE 429-6 <br /> TANK OWNER NAME 414. 1 PHONE 40. <br /> 1e4 1 ( A 3 ` 7� <br /> MAILIN ADDRESS 416• <br /> as Z/ -*- <br /> C Y acz 1 STATE 416. ZIPCg�E 3-3 6 419. <br /> C... 6Q f<r <br /> OWNER TYPE; '194.LOCAL AGENCY(DISTRICT ❑ 5.COUNTY AGENCY C ❑ 6.STATE AGENCY 420• <br /> d 7.FTs'T)ERAL AGENCY d R.NON-GOVERNMENT <br /> JWA OPT ,UST:STORAGE FEE.ACC4 <br /> Ty(TY)UQ 44. Call the Statc Beard of Equalization,Fucl Tax Divi-ipn,if there arc question 421. <br /> Ia!wze pegmit and send Icgal natifications and nailing to: Ir I.FACILITY OWNER d 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ S.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Requlmd For Public Agencies Only) , <br /> „e <br /> CEM <br /> FICATION: I certify dtat the intimation provitled herein is RCcal19 snd ten fall ce w[th al regairementL <br /> APPLICANTS[G DA gw /Q 424 PHONEOS . <br /> APPLI AME(print) 6 APPLICA TITLE �+AC3 Q7 <br /> UPCF UST--A Raw.p <br />