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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TAMC <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per thei I ity) <br /> TYPE,OF ACTION C1 I-NFW PERMIT 015.CHANGE OF INFORMATION El TPERMANEN'rFACiLITEY CLOSUR4M <br /> (Check one item otily) ❑ 3.RENEWAL PERMIT El 6.TEMPORARY FACILITY CLOSURE D 9 TRANSFER PERMIT <br /> .................I................... <br /> I.'F <br /> TOTAL NUMBER OFUSTs AT FACTLITY 404, <br /> FACIIJTY ID# <br /> (Agency(Ise Only) .. ........ <br /> BUSIN E.SS NAME(Smut am FACILITYNAY&orDBA-Doing BusmXWAs) <br /> zbs pe4 - b Bq <br /> 'yp ivy <br /> BUSINESS SITE ADDRESS 103, CITY <br /> (P3,3 • Q tcA-by- P-c(err S-AC A 403405. <br /> El <br /> FACILITY TYPE MOTOR VEBICLE FUELING El 2.FULL DIST .RIBU11ON Is tho facility located on Id'EReservation or <br /> 3.FARM 4.PROCESSOR El 6. = El OTHER I Tlands? Yes 0 <br /> ............. . ......7 — .. .. .... 11 <br /> . ............ <br /> J <br /> PPR ::OWNWIN RMATI <br /> ON <br /> PROPERTY OWNER NAME 407. PITONE 40R. <br /> MAILING ADDRESS 1 409. <br /> ( It It <br /> CITY ok'M 411- ZIPCOT)E 41Z <br /> CiA '5kS2-k4 0 <br /> -N F P'm <br /> Wk.f.0k :0 <br /> A <br /> TANK OPERATOR NAME,, 421-1 PHONE 121,2 <br /> MAILING ADDRESS 42F-73- <br /> CITY 4291 STATE 128-5 ZIP CODE <br /> )k �T.1 N <br /> M. 'R IN 0 <br /> TANK OWNER NAME 414. PHONE 415. <br /> ('AGO` T b-77 51 <br /> MAMING A49MSS 1-c*ov- PC-16 <br /> CITY _ 412 STATE 419. ZIP COD 4M <br /> 1 C-A- �; c <br /> OWNER,TYPE: D 4.LOCAL AGENCY/DISTRICT E] S.COLJNTY AGENCY ❑ 6.STATE AGENCY 420, <br /> ❑ 7.FEDERAL AGENCY JP4.NON-GOVERNMENT <br /> .10Z <br /> V.::B ARD�*:C ALtAT-10k:USTSTORM <br /> ACE FEE ACCOUNT NUBER : <br /> . . '.....1......% : QV <br /> Ty(TK)I IQ 44- It> S Call the State Board of Equalintion,Fuel Tax Division.if there are questions. 421. <br /> :VLPER-MIT I40LDERINFO R'MATIOINI, <br /> Issue pennit and qcM 100A notifications and mailings to FACILITY OWNER El 4.TANK OPERATOR .123 <br /> 3.TANK OWNER Q 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies -)n[y) 406, <br /> V-11.:APPLICANT,SI.0 NATURE <br /> CFRTMCAT10N-. I eertif the information provided hemiais true,accurate,and idfull s!nRlienee with 1m]requirements. <br /> APPLICANT SIGNATUX43. PHONE 425 <br /> 7( 2Mw. <br /> APPLICANT NAME,(prin 426 APPIA.ANT TITLE <br /> k Lel Lou- /11 <br /> XJPCF UST <br /> -A Rev.(12/2007) <br /> TTO/ 900'd SL90# 6Z:90 90OZ/ZZ/LO <br />