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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[ 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) I <br /> BUSINESS NAME(sanenmcBanrmmEorDBA-Doing B As) 3• <br /> W ATEIZ FOO ILE <br /> BUSINESS SITE ADDRESS 103• CITY 104. <br /> 0 3 r W C' Y t� C1 405 <br /> FACILITY TYPE �`1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION ' Is the facility located on Indian Reservation or ' <br /> 3.FARM 4.PROCESSOR 6.OTHER Trust lands? ❑Yes No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME IN C_ 40.1. PHONE 408• <br /> WATER LM Emp U EL <br /> MAILING ADDRESS 409. <br /> Gc� W1n e <br /> CITY 410. 1 STATE 411. ZIP CODE 412. <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME N J PHONE 428-2 <br /> MAILING ADDRESS _ - - 428-3 <br /> CITY 426-4 STATE 428.5 ZIP CODE 428.6 <br /> IV. -TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. 1 PHONE 415. <br /> MAILING ADDRESS 416. <br /> CITY 417, STATE a18. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY NON-GOVERNMENT <br /> V. BOARD'OF EQUALIZATION UST`STORAGE_FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI. ERMIT 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 /> SUPERVISOR OF DMSION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VIL APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein h frac acture and In fall com nce with t da. <br /> uireme - <br /> APPLICANT SIGNATURE �� DATE 424. 1 PHONE 425. <br /> _et <br /> APPLICANT NAME 426• APPLICANT TITLE a an <br /> UPCF UST-A Rev.(12!2007) `",, <br />