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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT `P'5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 40a. FACILITY ID# 1 <br /> (Agency Use 0 <br /> n1y) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. <br /> + 0 S <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING E] 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? []Yes No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> '8va' /Y J <br /> MAILING ADDRESS 4M <br /> CITY 410 STAT 413. ZIP CODE alz. <br /> Coo, 95-P 4 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAM 428-I. PHONE azs-z <br /> 1940 <br /> MAILING ADDRESS 428-3 <br /> CITY ` / 428-4 STAT�y azs-s ZIp CODE <br /> 428-6 <br /> /��7 9 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. 1 PHONE 415. <br /> MAILING ADDRESS 416. <br /> CITY alz STATE <br /> 'TPCZIPC{dDE 4M <br /> >5 <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 ST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 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 � TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER �J 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> :";'-'� <br /> CERTIFICATIO 9certify that the information provided herein is true,accurate,and in full com liance with legal re uirem ` <br /> APP IGNA E DA fE / � 424. PHONE �,,;,,�: � azs. <br /> i 30/0 w41 3L�1 :� v <br /> APPLICANT NAME(pr� 426. AP T TITLE f- .^"� an <br /> UPCF UST-A Rev.(12/2007) <br /> seat . dId <br />