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tell <br /> UY IED PROGRAM CONSOLIDATED FO " k� -� <br /> UNDERGROUND STORAGE TANK 'j) )Z)1 D <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) 14 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTS AT FACILITY FACILITY ID.# <br /> 3 (Agency Use Only) ) U <br /> $S NAME(Sarre as FACILITY NAME or �-Poing Business Ass) �1 . <br /> BUSINESS CITF A IIRRQe-_ tai• CITY ta4. <br /> 915b-571 � . J )e 4CAn P <br /> FACILITY TYPE %0-l.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes 04 No <br /> n _aa II, PROPERTY OWNER INFORMATION <br /> tPROPE TY OWNER NAME 407. 1 PHONE 408. <br /> h 409. <br /> MAILINGADDRESS <br /> �• (/ � ,�� <br /> CITY 410. 1 STATE 41 t• ZIP CODE s-b 412• <br /> OA-r-V l LLQ Cot- <br /> III. <br /> o -III. TANK OPERATOR INFORMATION <br /> TANK OPERATnit-P <br /> AME <br /> 428-1. PHONE 428-2 <br /> ren (269 ) 3 1.7 <br /> MAILING ADDRESS a28-3 <br /> 122 -( 'V`i�rlQ <br /> CITY / % 4284 1 STATt. 428-5 ZIP CODE 428-6 <br /> INFORMATION <br /> ANK OWNER N E Ota. 'PHONE 4ts <br /> , `- � /? Y <br /> MAILING ADDRESS -.. _ _-.. 416. <br /> 171 V <br /> V-A <br /> � �ey)n a Y <br /> CITY // <br /> tic <br /> at7. STATE 418• ZIP CODE Z�.y_ 419. <br /> L�oDi I Gid <br /> OWNER TYPE: [14.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OFEQIIA12t &TION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TY-)HQ 44_ \ Call the State Board of Equalization,Fuel Tax Division,if there are questions. alt. <br /> - HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER 4.TANK OPERATOR 423 <br /> ❑ 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 /> CERTIFICATIO I certify that the inf rmation rovided herein is true,accurate and in full compliance with legal requirements. <br /> APPLICANT SI A RE DATE 424. PHONE 425. <br /> 333 0.3 os <br /> 426. APPLICANT TITL 427 <br /> APPLICANT N (print) r.-L1- <br /> 214 <br /> UPCF UST-A Rev.(12/2007) <br /> .n <br />