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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400' <br /> (Check one item only) ER 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# __jfTj1 _ 1 �j� t' <br /> (Agency Use Only) Y <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-�D^oing Business As) 3. <br /> G " ©* V- 7 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 'Z9 . <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING [12.FUEL DISTRIBUTION ao3. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ES No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. 1 PHONE 408. <br /> .41j /_ 2 UM ti(a - 7to;L I <br /> MAILING ADDRESS 4ov. <br /> M A'4-T y z <br /> CITY 410. 1 STATE 411. 1 ZIP CODE 412. <br /> C_$1 G S Z U �v <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> A (a UGI ) 11QA --7to� 1 <br /> MAILING ADDRESS 428-3 <br /> CITYazsa STATE 428-5 ZIP CODE 428-6 <br /> S'To C-1pr ri s_Zv L_ <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Iq 0 i s ( 2 tC z- -7 ('z 1 <br /> MAILING ADDRESS 416. <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> 5'70 cli-n)-i G/I G<_ <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- 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: JR 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 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 SIGNATUW DATE 424. PHONE 425. <br /> Gam- G - l 7 -/ ;_7 0 'I <br /> APPLICA pri 426. APPLICANT TITLE 42,7 <br /> � . <br /> UPCF UST-A Rev.(12/2007) <br /> 7 <br /> is U <br />