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11 6 0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK �� <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION400. <br /> ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE 0„9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404 FACILITY ID# _ t <br /> (Agency Use Only) <br /> BUSINESS NAME(Sme as FACILITY NAME or DBA-Doing Business As) 3. - <br /> (•O<i� i2 i--f'cam• <br /> BUSINESS SITE ADDRESS 103. CITY 104 <br /> <-, <br /> FACILITY TYPE K,I.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 LINO <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME40'. <br /> PHONE aos. <br /> MAILING ADDRESS r 409 <br /> v 25- ® ev <br /> CITY 410. STATE 411. <br /> ZIP CODE 412. <br /> III: TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 4za-2 <br /> MAILING ADDRESS a 428-3 <br /> Vf <br /> CITY azs a STATE 428-5 ZIP CODE 42" <br /> CA <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. 1 PHONE 415. <br /> MAILING ADDRESS _ 416. <br /> CITY 417. 1 STATE 41s. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY <br /> ❑ 6.STATE AGENCY azo. <br /> ❑ 7.FEDERAL AGENCY 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- TAJ3 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 K4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify t_h,Lthe q(ormation provided herein is true,accurate,and in full compliance with legal re uirements. <br /> APPLICANT SIGNA � -- DATE 424. PHONE azs. <br /> r <br /> APPLICANT NAME(print) 426• APPLICANT TITLE Yv 427 <br /> F <br /> UPCF UST-A Rev.(12/2007) <br />