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a <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> NG PER <br /> OPERATIMIT 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 <br /> ❑ 6.TEMPORARY FACILITY CLOSURE q9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. <br /> BUSINESS SITE ADDRESS 103. CITY 754- <br /> SIC k d Q o- _ '-moo <br /> 1 c <br /> FACILITY TYPE 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 i'No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408_ <br /> MAILING ADDRESS 509. <br /> CITY 410. STATE 411 ZIP CODE 512. <br /> s <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME / 4M., 1 PHONE 428-2 <br /> MAILING ADDRESS 428-3 <br /> A-vf <br /> CITY 428A STATE 428-5 1 ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 4715. PHONE 415. <br /> MAILING ADDRESS 416 <br /> '7L`y t%�l�Cvtz r A-� <br /> CITY an. 1 STATE ala. ZIP CODE 419. <br /> 5"T L'�' �--TC ,v cUa- q 5'"-;- i 2-- <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY fk 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 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 /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certif that_the in[ormation provided herein is true,accurate,and in full com fiance with le al re uirements 3 <br /> APPLICANT SIGNATU DATE 424. PHONE '°f 4 <br /> JY <br /> APPLICANT NAME rent ` C-t� r7 <br /> (print) 426/ APPLICANT TITLE <br /> 0, <br /> UPCF UST-A Rev.(12/2007) `/¢ <br /> t• <br /> L <br />