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FIED PROGRAM CONSOLIDATED FOMW 1�� <br /> UNDERGROUND STORAGE TANK �� v <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION� Z '�I(( <br /> ( ne form-per f ility� <br /> TYPE OF ACTION ❑ 1.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#Cq <br /> (Agency Use Only) J <br /> BUSINESS NAME(Same as FACII.TTY NAME or DBA-Doing Business AS) 3. <br /> IFFV <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> FACILITY TYPE OErl.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403 Is the facility located on India Reservation or 405. <br /> ❑ 3.FARM [:14.PROCESSOR El 6.OTHER Trust lands? El Yes [PNo <br /> SII, PROPERTY'.OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> MAILING ADDRESS 409. <br /> 1P, ;'-2, <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> �A- gs-2-b 2- <br /> 111. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. 1 PHONE 428-2 <br /> ul)rZ on q ) et 6F 46 4s- <br /> MAILING ADDR YES§ 428-3 <br /> 7C OZ) /tom` /141 Comic 6c- c.+rt,)1,ts <br /> CITY 428-4 STATE 428-5 1 ZIP CODE 428-6 <br /> IV. TANK OWNER.INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> 4-A) J OA-O-uC AJ Cts L)��� <br /> MAI1,I�ADDRESS 416. <br /> `{Y� 417 STATE <br /> 418 ZIP CODE 419. <br /> CIT <br /> S � <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT M5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. -BOARD OF EQUALIZATION UST'STORAIGE FEE ACCOUNT NUMBER <br /> TY(TK)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 /> V3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. - <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VIL APPLICANT SIGNATURE ;N <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal re ui,gkne +s. <br /> AP I ANT SIGN TURF DATE 424. 1 PHONE ; 425. <br /> PLICANT NAME(print) 426. APPLICANT TITLE w 427 <br /> G ;_. <br /> rg t <br /> UPCF UST-A Rev.(12/2007) <br />