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Alsssss 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 ate. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT L FACILITY INFORMATION TOTAL NUMBER OF USTs AT FACILITY 4D4' FACILITY ID (Agency Use Qnly) BUSINESS N"(sameas FACILMY NAVE or BA-Doig As) 3 Ke BUSINESS SITE ADDRESS 103. CIq y 104. /- z 6 !; FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ Z FUEL DISTRIBUTION Is Is the facilitflocatd on Indian Reservation or 405. 3.FARM 0 4.PROCESSOR 0 6.OTHER I Trust lands? ❑Yes W No IL PROPERTY OWMR INFORMATION PROPERTY OWNER NAME 407• PHONE 408. IC � ate. MAILING ADDRESS CITY 41o. STATE alt. ZIP CODE 412 o J M. TANK OPERATOR INFORMATION TANK OPERATOR NAME 428-1. PHONE 428-2 4� )A v ( O/,) -5-7:3 428-3 MAILING ADDRESSCTry J r e- 4e 1 STATE 429-5 ZIP CODE 429-6 IV. TANK OWNER INFORMATION TANK OWNER NAW 414. PHONE 415. MAILING ADDRESS alb. el CITY 417. STATE 418. ZIP ODE 419. '15-03-5 OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT '.7�,, V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. VL PERMIT HOLDER INFORMATION <A r 4'e- Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 3.TANK OWNER ❑ 5.FACILITY OPERATOR 406. SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) VII.APPLICANT SIGNATURE CERTIFICATION: Icethat the informadon rovided herein is true accura and in full fiance with 1 r uirements. APPLICANT SIGNATURE DATE 424. PHONE 425. /_ ®r_ of `fo x APPLICANT NAME 426. APPLICANT TITLE 427 (print) Sy UPCF UST-A Rev.(12/2007)