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UNIFIED PROGRAM CONSOLIDATED FORM r <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATI <br /> (One form per facility) �( <br /> TYPE OF ACTION Sri.NEW PERMIT El 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Chea one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT11lI <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY 1D# <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> Fw6ma- Lama FA-c retry <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 2 X21 W Wk/�N�n,� ST S'h►te�-m�1 <br /> FACILITY TYPE [I1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405' <br /> ❑ 3.FARM ❑ 4.PROCESSOR 6.OTHER Trust lands? ❑ 1.Yes 2.No <br /> II. PROJPFIRT OWNER INFORMATION <br /> PROPERTY OWNER NAE 407• PHONE a40.M <br /> TQ)An1 Pct Io1cA{'r-..r 6tj1� g2f- Zo6z <br /> MAILING ADDRESS 409. <br /> 4ww <br /> a1o. STATE 411• ZIP CODE t z�� 412. <br /> CITY 6 <br /> P?�utir--_ <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME a$�• PHONE azs-z. <br /> u VXN#V1A✓) c ) <br /> MAILING ADDRESS 429.3. <br /> CITY 4284• STATE 428-5. ZIP CODE 428.6. <br /> IV. TANK OWNER INFORMATION` <br /> ,:_. . <br /> TANK OWNER NAME CUtyJGrmrN) 414. PHONE 415. <br /> ( ) <br /> MAILING ADDRESS 416' <br /> CITY <br /> 417.1 STATE 418, ZIP CODE 412 <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 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> 423. <br /> Issue pennit and send legal notifications and mailings to: ❑ I.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I cern that the information provided.herein is true accurate and in full com liance with legal requirements. <br /> APPLIC2A� NA URE DATE 424. PHONE 425• <br /> Zt oc+ Z• tr y(6 9LY-97791 x•11 <br /> APPLICANT NAME(print) 426• APPLICANT TITLE 427 <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />