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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# _ _ 1' <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as FACII.rrY NAME or DBA-Doing Business A0 3. <br /> w a C'�e�f 1 w ( cam cP <br /> BUSINESS SITE ADDRESS 103. CITY104. <br /> 10'3 Z.-. %,in he'A 6.0 <br /> FACILITY TYPE 2 1.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 ❑No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME W f Va C \ 1-7,n C 407. PHONE G' 6 „ * 408. <br /> MAILING ADDRESS J 1 f (0 409. <br /> '3'0 ot b�,�VV , <br /> CITY 410. STATE 411. ZIP CODE 412• <br /> 5��� C_<-) 11S yn� <br /> III. TANK OPERATOR INFORMATION <br /> PHONE 428-2 <br /> v� <br /> TANK OPERATOR NAME nQ S\ �t 428-1. ` l b r <br /> MAILING ADDRESS v1 r 428-3 <br /> CITY 4'8azs- C� azs <br /> ZIP CODE <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME � Q �w C �p�¢ 414. /PHONE als. <br /> V`l l <br /> MAILING ADDRESS 416. <br /> CITY 417. STATE 418_ ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 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(TK)$Q 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421' <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 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 re uirements. <br /> APPLICANT S[GNATUDATE <br /> 424. PHONE azs. <br /> (� F' S ( c �^ 2� Io9 <br /> APPLICANT NAME(print) 426• APPLICANT TITLE an <br /> UPCF UST-A Rev.(12/2007) <br />