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UNIFIED PROGRAM CONSOLIDATED FORM n <br /> UNDERGROUND STORAGE TANK Of <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) ❑ 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF U�Ts AT FACILITY 41' FACILITY ID# _ _ t' <br /> C_ ! (Agency Use Only) L <br /> BU NESS NAME(Same as Facility Name or DBA-Doing Business As) 3 <br /> An1Aq ci (no k 5 HopO <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> Pa c c- ve S ck�A) <br /> FACILITY TYPE � 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION ao3. Is the facility located on I dian Reservation or aos. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes X 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE aos• <br /> '1" W *1 2°9 S/- /� <br /> MAILING ADDRESS 409. <br /> ,26$' C roake_D r K C. cj e <br /> CITY 410. STATE 411. ZIP CODE ate. <br /> c �afV c A a 572 <br /> 1 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2. <br /> RAtSY1� FNA <br /> MAF <br /> G ADD SS 428-3. <br /> CIT4284. STATE 428-1. ZIP CODE 428-6• <br /> tj CA q__ <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME414. PHONE 415. <br /> R T w rr" ( ZQy 9S �- <br /> MAILING ADDRESS 416. <br /> 02 >SS- U06kej ShCCiMC- <br /> CITY C � 417. STATE. 411. ZIP CODE Z 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY jK 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 101Y1017191'6 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: 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423. <br /> V1.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 certifV that the information provided herein is true accurate and in full compliance with legal requirements. <br /> AP RE DATE 424. PHONE "' 421. <br /> APPLI NT NAME(print) 426. APPLICANT TITLE 427 <br /> 10 <br /> UPCF UST-A Rev.(1212007)-1/2 www.unidocs.org <br />