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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK l OPERATING PERMIT APPLICATION-FACILITY INFORMATION (One form per facility) TYPE OF ACTION ❑ 1.NEW PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT Ie FACILITY INFORMATION TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# _ (Agency Use Only) JZJ BUSINESS NAME(s..FAciLrrYNAMEorDBA-Doing Business As) 3• I^/A TL R��© 'r000 AU L BUSINESS SITE ADDRESS t03• CITY104. .303 AWC- 4Zoo �'�, SipCk'i4)/1/ FACILITY TYPE gl.MOTOR VEHICLE FUELING [12.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 405. 3.FARM 4.PROCESSOR [16.OTHER Trust lands? ❑Yes ❑No II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME407. PHONE 408• "� da-4d 6/2310 ) MAILING ADDRESS 409. Com, 410. 1 STATE 411. ZIP CODE 412. III. TANK-OPERATOR INFORMATION TANK OPERATOR NAME 428-1. PHONE 428.2 (916 ) Y6-5--3616 MAILING ADDRESS 428-3 ._fid CITY _ 429 4 STATE 428-5 ZIP CODE 428.6 IV. -TANK OWNER INFORMATION TANK OWNER NAME 414. PHONE 415. MAILING ADDRESS 416. CITY 417. 1 STATE 418. ZIP CODE 419. OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT V. BOARD OF EQUALIZATION USTSTORAGE-FEE ACCOUNT NUMBER TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. VI.PERMIT SOLDER INFORMATION Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ® 4.TANK OPERATOR 723 ❑ 3.TANK OWNER �.5.FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. VII.APPLICANT SIGNATUR CERTIFICATION: I ce. that the ipfgrmation provided herein is trae accurate,and in full compliance with legal requirements. APPLICANT SIGNATURE DATE 424 PHONE 425• APPLICANT N (print) 426. APPLICANT TITLE 427W L, S r f UPCF UST-A Rev.(1212007)