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c11 I I/I )k 67 <br /> FIED PROGRAM CONSOLIDATED FO <br /> UNDERGROUND STORAGE TANK t"� - Il�l ��' 7 <br /> OPERATING PERMIT APPLICATION-FACILITYORM�ITI N <br /> �/1'� fd(aper cili ) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ry( 5.CHANGE OF INFORMATION400. <br /> ❑ 7.PERMANENT FACILITY CLOSURE <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# _ O ,` 1. <br /> J (Agency Use Only) CJ <br /> BUSINESS 9AME(Same as FACILITY NAME or DBA-Doing Business As) 3. <br /> BUSINESS SITE A DRESS 103. CTTy 104. <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑��2.FUEL DISTRIBUTION 403. Is the facility located on Indi Reservation or 405. <br /> E:13.FARM El 4.PROCESSOR IIIT 6.OTHER Trust lands? ❑Yes ukrNo <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. 1 PHONE 408. <br /> Cab v <br /> AILING ADDRESS 409. <br /> CITY Oto. STATE 411. 1 ZIP CODE 412. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE azs-z <br /> f' 'fl �// 4 UN > <br /> MAILING ADDRESS 428-3 <br /> 7006 '' i <br /> A <br /> CITY 418-4 STATE 428-5 ZIP CODE 428-6 <br /> _•, &-A- Q �Z- <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> (:�3044'1 <br /> MAILING ADDRP 416. <br /> 2 L SGa7 v =' <br /> CITY 417. STATE ats. ZIP CODE 419. <br /> (-- <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT EK5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> a< TY(TK)HQ 44- 1 1 1 1 1 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: 423 <br /> P g g ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> AML <br /> 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> VP SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) I r, <br /> L A-1 Z- <br /> VII.APPLICANT SIGNATURE <br /> CERT ICATION: I certify that the information provided herein is true accurate and in full compliance with legal requirements. <br /> APP C NT SIGNA E DATE424. PHONE , <br /> A P CANT NAME(print) 426. APPCICANr TITLE 427 <br /> UPCF UST-A Rev.(12/2007) <br /> 1 _ i <br />