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�`1 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - FACILITY INFORMATION (One form per facility) TYPE OF ACTION ❑ 1. NEW PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 7. PERMANENT FACILITY CLOSURE 400. (Check one item only) 3. RENEWAL PERMIT ❑ 6. TEMPORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF UST's AT FACILITY 404. FACILITY ID # 2 (Agency Use Only) BUSINESS NAME (Same as FACEMY NAME or DBA -Doing Business As) 3. lf4cl,F I C_ +- 5 BUSINESS SITE ADDRESS 103. CITY 104. • -r/ I Fle- 4vU' 5-rs s-1 FACILITY TYPE (er1. MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 405. ❑ 3. FARM ❑ 4. PROCESSOR ❑ 6. OTHER Trust lands? ❑ Yes ❑ No II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407. PHONE 408. 2 wd A-7T�- MAILING ADDRESS 409. (02-&C C-" o lG e D s TZe,/C a 9-c, LC CITY 410. STATE 411• ZIP CODE 412. ,S%b c k (b ,t l 1 C q G�12, ! 1 M. TANK OPERATOR INFORMATION TANK OPERATOR NAME 429-1. PHONE 428-2 F,W 2120 Ct*s!L6-1P4 MAILING ADDRESS 428-3 3 ea s <a c�19-1� c c �t CITY 47 STATE 428-5 ZIP CODE 428-6 7 -&Lk TO'-/ C-*+ 4 N IV. TANK OWNER INFORMATION TANK OWNER NAME ala. PHONE 415. MAILING ADDRESS 416. &%-& C -fl -'L' ac- (C,l CITY 417. 1 Is X44 STATE 418. ZIP CODE 419. OWNER TYPE: ❑ 4. LOCAL AGENCY/DISTRICT ❑ 5. COUNTY AGENCY ❑ 6. STATE AGENCY 420. ❑ 7. FEDERAL AGENCY 6 8. NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY (TIC) HQ 44- Call the State Board of Equalization, Fuel Tax Division, if there are questions. 421' VI. PERMIT HOLDER INFORMATION Issue permit and send legal notifications and mailings to: (5 1. FACILITY OWNER ❑ 4. TANK OPERATOR 423 Er 3. TANK OWNER ❑ 5. FACILITY OPERATOR SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies Only) 406. VII. APPLICANT SIGNATURE CERTIFICATION: I certify that the information provided herein is true, accurate and in full compliance with legal requirements. APPLICANT SI N DATE 424.PHONE �2 3, a 9 425• wog y 33- / i "} APPLIC ► az6. APPLICANT TITLE 427 fie" s e2 , . o y Er'rTo ,e- UPCF UST -A Rev. (12/2007)