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GO ,�I <br /> 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 ❑ 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 41. 1 FACILITY ID# _ 1 <br /> 3 (Agency Use Only) pZ <br /> BUSINESS N (Sameas FAC MY DBA-Doing B_s P;As) '. <br /> BUSINESS`SITE ADDRESS � 103. CITY 104. <br /> FACILITY TYPE e 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403 Is the facil located on Indg* n Reservation or aos. <br /> El 3.FARM 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes A o <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY O ER 407 PHONE 408. <br /> MAILING ADDRESS 409. <br /> / <br /> CITY 410. 1 STATE 411. ZIP CODE 412. <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR N 428-1. PHONE 428-2 <br /> MAILING ADDRESS 428-3 <br /> CITY 4284 1 STATE 428-5 1 ZIP CODE 428-6 <br /> W. TANK OWNER INFORMATION <br /> TANK OWNER AME 1 414. 1 PHONE 415. <br /> MAILING ADDRESS 416. <br /> CITY <br /> an. 1 STATE 418. ZIP CODE 419. <br /> s�3.5 <br /> OWNER T E: ❑ 4.LOCAL AGENCY/DISTRICT ❑ S.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT 915 <br /> V. BOARD OF EQUAL TION UST STORAGE FEE ACCOUNT N&MER <br /> TY(TK)HQ 44_ / Call the State Board of Equalization,Fuel Tax Division,if there are questions. a_t. <br /> l <br /> VI.PERMIT HOLDER INFORMATION 1wa .9�G <br /> Issue permit and send legal notifications and mailings to: 131.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> P'3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the infqrmation provided herein is true,accurate and in full compliance with legal requirements. <br /> APANT SIGNATURE DATE 424• PHONE 425 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> l2�iS.s Iyfc �/l�9 //I-mac`/o <br /> UPCF UST-A Rev.(12/2007) <br />