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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK loot <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facilit <br /> TYPE OF ACTION ❑ 1.NEW PERMIT �.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 FACILITYFACILITY ID# _ _ �j Il 1 <br /> S (Agency Use Only) /� t L <br /> 71 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Bmi/new As) 3. <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 405. <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403 is the facility located on Ind' Reservation or <br /> [13.FARM 4.PROCESSOR 6-OTHER Trust lands? ❑Yes No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> wA-7�P4i,6U f� "D � Ft, Iti L 409. <br /> MAILING ADDRESS <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME4 PHONE 428-2 <br /> MAILING ADDRESS 425-3 <br /> CITY 4284 STATE azs-s ZIP CODE 428-6l-w '\-) � V l _V C�f� of 4 %P <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 41IN PHONE 415. <br /> 416. <br /> MAILING ADDRESS <br /> CITY 417 1 STATE � ala. ZIP CODE 'i G/) �� � 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)HQ 44_ L I I I I Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> 423 <br /> Issue permit and send legal notifications and mailings to: 1.FACILITY OWNER [14.TANK OPERATOR <br /> ❑ 3.TANK OWNER A 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VIL APPLICANT SIGNATURE <br /> CERTIFICATION: Xcertify that Ac information provided herein is true,accurate,and in full compliance with 1 al requirements. <br /> APPLICANT SIGNA DATE _71,2424. PHONE 425. <br /> APPLICANT NAME rint / /' a� APPLICANT TI M - <br /> WW b. ,?Re�. •� < <br /> �a <br /> UPCF UST-A Rev.(12/2007) JUL 18 2012 ' <br /> pie _ s "Ty <br /> 'i <br />