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ey <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 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# <br /> I S $ <br /> (Agency Use Only) <br /> BUSINESS NAME(SameaFACiLrr � mesAs) <br /> ATS <br /> T B - lC <br /> 3' <br /> W DLsI <br /> o f <br /> BUSINESS SITE ADDRESS ,n 103 CITY 1 O ,I`�O CI�,t) <br /> �Z�11 w �'� I �! 1 F- <br /> FACILITY TYPE .1.MOTOR VEHICLE FUELING El2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or aos. <br /> 3.FARM 0 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ;-No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407• PHONE 401. <br /> 5A / i a at � &1) 93/ <br /> MAILING ADDRESS i7 409. <br /> sz l � w�T <br /> CITY KT410- STATE 411. ZIP CODE 412. <br /> aJ`( -• C � � S �Js- <br /> HI.TANK OPERATOR INFORMATION <br /> TANK OPERAT R NAME ` azs-1. PHONE 428-2 <br /> Lw ) <br /> I SJ �`� � � c2��> !o tj • �I33 <br /> MAILING ADDRESS ,.A; 428-3 <br /> CITY <br /> 428 a STA �^ 428-5 ZIp � �_ 428-6 <br /> S 7-0 C <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME Af-P O ala. PHONE 415. <br /> s� � D � 61fc � <br /> MAILING ADDRE> �, '�'7 j'C/?/� r'f at6. <br /> � <br /> CITY _ p a17. 1 STATE .n 418. ZIP CODE ., [� r - 419• <br /> 5 /O c �1 C V7' cf J p[ J <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(TIC)HQ 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:Aertify that he information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICA (71SIGNAT w` Y DATE /D/ / �4 PHONE O 4 3 <br /> 25. <br /> (print) , , 41 <br /> 4'-6 APPLICANT TITLE 427 <br /> APPLICANT AME <br /> }2 S►l� 4J l� j0 lZ- <br /> UPCF UST-A Rev.(12/2007) <br />