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�1 <br /> UNIFIED PROGRAM CONSOLIDATED FORM 3 <br /> UNDERGROUND STORAGE TANK Q <br /> y ��` lam►/ <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION K�` l <br /> (One form per facility) <br /> TYPE OF ACTION El 1.NEW PERMIT R5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE aoo. <br /> (Check one item only) ❑ 3 RENEWAL,PEST ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I: FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY FACILITY M# <br /> (Agency Use Only) I <br /> BUSINESS NAME(Same as FACILM NAME or DBA-Doing Bminem As) 3. <br /> BUSINESS SITE ADDRESS 103' CITY roti. <br /> FACILITY TYPE ,� 1.MOTOR VEHICLE FUELING [12.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 405' <br /> 3.FARM 4.PROCESSOR P.6;OTHER Trust lands? ❑Yes No <br /> II. PROPERTY OWNER INFQRMATIQN <br /> PROPERTY OWNER NAME / 411. PHONE <br /> aos. <br /> 79 <br /> MAILING ADDRESS aay. <br /> 1�71D0 � �cc�ton� Sp1 <br /> CITY a1o. STATE an. ZIP CODE 412. <br /> III. TANKOPERATOR YNFORMATIQN <br /> TANK OPERATOR NAME 428-1. PHONE 428.2 <br /> 75 7 <br /> MAILING ADDRESS 428-3 <br /> CITY 42&4 STATE 428-5 ZIP CODE 428.6 <br /> IV. TANK OWNERINFORMATION <br /> TANK OWNER NAME <br /> ala. PHONE 415. <br /> ✓3,-,L/ "'/ !� tate f ( ) �t79 <br /> MAILING ADDRESS ,r 416' <br /> CITY 417. STATE 418• ZIP CODE 419. <br /> S /o k 10 �' cl 5� <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARS OFQiTAITZATION UST STE}RAGEFEI' AGOi�1iT I�FT1V1$ER <br /> ' Call the State Board of Fuel Tax Division,����HQ 44- � y� Equalization, n,if there are questions. <br /> 421. <br /> VL PERMIT HQLDER.IlriFORl41AT ' <br /> Issue permit and send legal notifications and mailings to: 1.FACILITY OWNER 4.TANK OPERATOR 123 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> PLICANT SIGNATURE <br /> CL(RTMCATION: I at the information 'ded herein is trae.accn and in&H Tm with uirementL <br /> PLIC SIGN A DATE <br /> I 9 112 <br /> 424. PHONE <br /> bPPLICANT NAME nt) 426- APPLICANT TITLE an <br /> 611 Nt <br /> r <br /> UPCF UST-A Rev.(12/2007) <br /> F <br />