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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> III I (One form per facility) <br /> TYPE OF ACTION 'l.NEW PERMIT C3 5.CHANGE OF INFORMATION ©7,PERMANENT FACILITY CLOSURE 400 <br /> � <br /> (Ck-t onetw only) ®1 RENEWAL.PERMIT []&TEMPORARY FACILITY CLbSURE ❑9.TRANSFER PERMIT <br /> L ;FAC,IIITX INF®Rl�?ifA�`�®N <br /> TOTAL NUMBER OF USTs AT FACILITY FACILITY TD# t. <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as RwWry Name Or DBA-Doing Business As) <br /> Rmpvir-t- LGrSCc? � �:YGtT'f , <br /> BUSINESS SITE ADDRESS �� CITY 164• <br /> ?M1 W WkfEi kATbw Sr Sfivc ars+J <br /> FACILITY TYPE (3 1.MOTOR VEHICLE FUELING Q 2.FUEL DISTRIBUTION 40' Is the facility located on Indian Reservatioa or 40 <br /> 5' <br /> 3.FARM 4.PROCESSOR 6.OTilER (nut lands? ® l.Yes T2.No <br /> u FRc►PERT'Y -,:FQ,'RMAT�[ON <br /> PROPERTY OWNER N �7- 4ai. PHONE . <br /> CkINl-Y0 -AN itf UY6:[I f t tu#f- 't'Y2- -&561 1 <br /> MAILING ADDRESS ate' <br /> I 1 0 wey� /N�dt+KR /JYe�s �dl t L <br /> CITY 410• STATE atl. .ZIP CODE � 7 412. <br /> M. TANK OPERATOR INFORMATION <br /> TANKOPERATOR NAME aas t• PHONE 4ML <br /> 411VXN#WAI) 2. <br /> N� G ADDRESS azs-4: <br /> CITY 4294. STATE 4�ss. Z[RCODE 42M• <br /> - N.. TANK O R INFO TION <br /> TANK OWNER NAME ata. PHONE ate. <br /> CA.ot-V4 SAti€�iv�?"%f '�R VfT 1041 ) �t`�iZ'63t f <br /> 416. <br /> MAILING ADDc�sS-o <br /> CITY (t alp. STATE sta :ZrPCODE. 419. <br /> w� Zak' 9 S2a? <br /> OWNER TYPE: ❑ 4,LGCAL.AOENCY/DTSTR[CT 0 5.COUNTY AGENCY O 6.STATE AGENCY 420. <br /> ❑7.FEDERAL AGENCY 3.NON-GOVERNMENT <br /> V. BO OF EQU II ATION UT,3T <br /> SORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Cali the State Board of Equalization,Fuel Tax Division,ifthereare questions. 421. <br /> VT.PERMTHOLDIERWORMATION <br /> tasue permit and send legal notifications and mailings to: (� .t.FACILITY OWNER ❑4.TANK OPERATOR 411 <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Onl) 406' <br /> VU.APPLICANT-$I 'NATURE. <br /> rCERTIFI ATIION : I certifythat the Information provided herein Is true,accurat and in full conn fiance with legal r uireateats. <br /> APF IC". . : NA RE DATE 41-4• PHONE. 4 <br /> APPLICANT,NAMErant),( , 426• APPLICANTTITLE 4Zt <br /> R t l(;1G <br /> UPCF UST-A Rev.(12/2007)-1/2 4vtvn:uatdoesorg <br />