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M t UNEFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One forts per facility) <br /> TYPE OF ACTION ❑ .NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400• <br /> (Check one it, only) 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I: FACELITYINFORMATION <br /> TOTAL NUMBER OF USTs ATTAC11TY 404' FACILITY ID# _ I' <br /> (Agency Use Only) <br /> BUSINESSN (Same asFACkftifNAME aDBA- Busin As) 3. <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> FACILITY TYPE I.MOT VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on In ian Reservation or 405' <br /> 3.FARM 4.PROCESSOR 6.OTHER Trust lands? ❑Yes XNo <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTYO NAME 407. PHONE 408. <br /> 17119 <br /> MAILING ADDRESS <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> A-f <br /> III. TANK OPERATOR INFORMATION., <br /> TANK OPERATOR 428-1. /PHONE- 428-2 <br /> l <br /> MAILING ADDRE 428-3 <br /> CITY 4254 STATE 428-5 ZIP COD 428.6 <br /> 6 <br /> Mlew <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME'S7} P 414. PHONE 415. <br /> V( w% �Z2 ::?-- <br /> V ®� <br /> MAILIN RESS 416. <br /> ® 4 � s <br /> CITY r 417• STATE 418. ZIP DFr� 419. <br /> OWNER TYPE: 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY `l/❑ 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- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLD INFORMATION <br /> Issue permit and send legal notifications and mailings to: I.FACILITY OWNER [14.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 4. <br /> VII.APPLICANT SIGNATURE <br /> CERT . I certify that the informa0o5Aovided herein is frite,accurs and In fpfl com fiance with IeVJ EMuirements. <br /> APPLIC SIGNATURE DATE 424• PHONE 4u• <br /> �- 3 <br /> APPLICXW N (print) 426• APPL T an <br /> ® LK f S <br /> UPCF UST-A Rev.(12/2007) <br />