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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) 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# <br /> •� (Agency Use Only) <br /> BUSINESS NAME(Same as FACB.rrY x orDDBA--thing Business As) 3. <br /> A/ -.moo g 'f j <br /> BUSINESS SITE ADDRESS 103• CITY 104. <br /> l�2 a ^•� <br /> FACILITY TYPE I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403• Is the facility located on Indieservation or 405. <br /> 3.FARM 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes 0'No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAMEA/ X�_ 467 PHONE 408. <br /> MAILING ADDRESSS <br /> I 409.o hof �QO � <br /> CITY 410 STATE 411• ZIP CODE alz. <br /> -. CA 't 6 2-6 cl <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> MAILING ADDRESS 428-3 <br /> CITY 4284 1 STATE 428-5 ZIP CODE 428.0 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414• PHONE 415. <br /> MAILING ADDRESS 416. <br /> CITY 47 STATE 418. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 55.COUNTY AGENCY ❑ 6.STATE AGENCY 420• <br /> F12 7.FEDERAL AGENCY a.NON-GOVERNMENT <br /> V.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TIC)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421' <br /> VI.PERMIT HOL ER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 1.FACILITY OWNER El 4.TANK OPERATOR 423 <br /> 0 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 the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE ) 474 PHONE µ. <br /> Z/7 / 2e7 1 <br /> APPLICANT NAME(print) 426• APPLICANT TITLE <br /> � 3 <br /> UPCF UST-A Rev.(1212007) <br /> �,f <br /> is�r <br />