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C� <br /> z � <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> r(JNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form per faciiity) <br /> TYPE OF ACTION 0 1_NEW PEKMff ❑ 5CH <br /> _ ANGE OF INFORMATION ❑ 7_PERMANENT FACILITY CLOSURE 400 <br /> ((:hey&ora nem rnrly) [3 3.PM4EWAL PO TT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L FACILITY'INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY FACH=0# T _ t <br /> . (,W�Use o*� <br /> BUS1NM NAME(Emirs z Fmlgy Nmne or DBA-I>&ag s'ss As) I� -S [ a. <br /> D b I s <br /> ]BUSINESS SITEADDRESS r°3. C ;� <br /> 4%. <br /> FACuITY TYPE 'a I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRI8U77ON 403• Ts the facl7ityy located onI�i�tu Rcscrvsmon Of <br /> ❑ 3.FARM [14,PROCESSOR 136.OTHIR lan <br /> Trust ds? [31.Yes ,8l 2.No <br /> ` M PROPERTY OWNER EWORMATION <br /> PROPERTY OWNER NAME PHONE <br /> �I��tsnr,4x 3�`t --1 s1 <br /> 409. <br /> MATLTNe AD11MS <br /> •3 3 412. <br /> CITY Oto. STATE, arr• ZTPCODE <br /> CA i <br /> M. TANK OPERATOR ROORMATION <br /> TANK OPERATOR NAME 4281• PT30NE "Z <br /> MAILING ADDRESS V{ �-'�V� �� "' ' � • <br /> (033 • 428-6. <br /> . STATE a 7IP CODE <br /> cTrY <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONF, art <br /> 416. <br /> IviATLINGAT)DRFSS <br /> ?? 417. STAT ala 7.iP CO�i£ q aty. <br /> Cl C1` (1 S , (� <br /> OWNER TYPE; p 4.LOCAL AGENCY/DISTRICTCI 5.COUNTY AGENCY © 6.STATE AGENCY a�Q <br /> p 7.FEDERAL AGENCY 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK.)HQ 44- Q 0 S Canto Stats Board of FgMmu-6 Facet Tax Dn-ioq if ft"arc quesiiew <br /> 4a1. <br /> VL PERMIT HOLDER I4 WORMATION <br /> 473. <br /> TWW Permit aW send 3cg�d 3300)catiORS WA mailings Lo: 1.FACILITY OWNER ©4_TANK OPERATOR <br /> 0 3.TANK OWNER © 5.FACTLrTY OPERATOR <br /> SUPhR VISOR OF DIVISION,SECTION,OP,OFFICE&—*p fired f-FWk Agues Only) <br /> VII.APPUCANT SIGNATURE <br /> C ERTIFICA£ION: I ee a information provided itertin is frac,�gra gild in full nom Itasca414, t I ire eents aZ <br /> APPLICANT S1GNA <br /> / 4.2& APPLICANT TITLE( 4D <br /> APPLICANT fTa�t ( / _ .f <br /> C��'Yl�+r <br /> UPCF UST A Rev.(17!1067)-In www.afsid9asoig <br /> 800/ Z00'd Z4Z0# 93:L0 SOOZ/£0/t0 <br />