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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400' <br /> (Check one item only) <br /> ®'3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# _ _ t' <br /> 7� (Agency Use Only) <br /> BUSINF�S NAM (Sameas FACILMY NAME or DBA-Doing Business As) 3. <br /> Q- ( O S K 0 L_L_ <br /> BUSINESS SITE ADDRESS 103. CITY <br /> 3Lc � & (� i P© N eI <br /> FACILITY TYPE I.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 opr.-. <br /> II. PROPERTY,OWNER'INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> MAILING ADDRESS I �. 1 SAF C 4 <br /> CITY C) 410. STATE 411. I ZIP CODE 4112. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. 1 PHONE 4228-2 <br /> A- LA C910 <br /> L- <br /> MAILING ADDRESS ^ ` 1' -�-�( 3 <br /> Af <br /> CITY �7 4'-8-4 STATE 428-5 ZIP CODE 4'-8-6 <br /> � PIE) jk-- <br /> -- t � C � s 3 10 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAMEj- 414. PHONE 415. <br /> MAILING ADDRESS 416. <br /> CITY 417. STATE 418. ZIP CODE I 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT 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(TIC)HQ 44- 1 o Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421' <br /> VI.PERMIT HOLDESPWORMATION, <br /> Issue permit and send legal notifications and mailings to: .FACILrfY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 4097 <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I ce the infor ation provided herein is true accurate,and in full com fiance with legal requirements. , <br /> APPLICANT SIGNATURE DATE 424• PHONE 425. <br /> 6 <br /> APPLICANT NAM 426. APPLICANT TITLE 427 <br /> UPCF UST-A Rev.(12/2007) r;,.�' <br />