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FIED PROGRAM CONSOLIDATED F <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 4M <br /> (Check rue;ic;m 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 /> d ", (Agency Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. <br /> \L Q,�S�i�- �--D UNN Ott. <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR &r 6.OTHER Trust lands? ❑Yes PO No <br /> II. PROPERTY OWNER;INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> MAILING ADDRESS 409. <br /> CITY <br /> alo. ST�� �� <br /> au. ZIP DLi alp. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1• PHONE 4'-8-2 <br /> `_mGee _ �O(.jNOP�r lbl� ��b5 j t, ( 2ly ) �SS'370(? <br /> MAILING ADDRESS 428-3 <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> MAILING ADDRESS 416. <br /> 1T7-7 w,YOS�I PNi <br /> CITY C � alp. ST�� 418. ZIP CODE � ��� 419.rn�o " <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- V o 5 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 411. <br /> VI.PERMIT FOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> 4,3 <br /> AL 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: I certify that the information provided herein is true,accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNAT U\I l G C 1-10r� DATE A 1- 0 1 424 ( n 0� ) 425. <br /> APPLICANT NAM (print) 4'-6• APPLICANT TITLE L J 417 <br /> SS S Ch I,F 4P407ee <br /> UPCF UST-A Rev.(12/2007) a <br />