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# • P <br />tT <br />DI <br />Awl <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />E: <br />OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br />(One form per facility) <br />TYPE OF ACTION ❑ 1. NEW PERMITFT 5. CHANGE OF INFORMATION El7. PERMANENT FACILITY CLOSURE 400. <br />(Check one item only) ❑ 3. RENEWAL PERMIT 6. TEMPORARY FACILITY CLOSURE <br />❑ ❑ 9. TRANSFER PERMIT <br />I. FACILITY INFORMATION <br />TOTAL NUMBER OF USTs AT FACILITY 404' <br />FACILITY ID # <br />_ <br />_ <br />t' <br />DAP <br />(Agency Use Only) <br />BPSINESS NAME (Same a,FACILrrY AME or DBA -Doing Business As) . 3. <br />^ <br />G 2r css <br />BUSINESS SITE ADDRESS 103. <br />CITY too. <br />L , Z 0 k (�_C <br />FACILITY TYPE ❑ L MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 403. <br />Is the facility located on Indian Reservation or 405. <br />❑ 3. FARM ❑ 4. PROCESSOR 6. OTHER <br />Trust lands? ❑ Yes XN. <br />H. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407• <br />PHONE 408. <br />� `rm,,_ <br />(yoz 271-.23a <br />MAILING ADDRESS 409. <br />ly pad <br />to <br />a1o. <br />CITYSTATE <br />411• <br />ZIP CODE 412• <br />D �k� <br />PC <br />�s/7,; <br />M. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 428-1. <br />'12,o,, _i; <br />PHONE 428-2 <br />bra Ue es 5- <br />(Cr7;- )_712 -5'6 7/ <br />tA LING ADDRESS 428-3 <br />elmo 61epty(He -2 A <br />CITY 411STATE <br />Rtc�4 �soN <br />428-5 <br />ZIP CODE 428.6 <br />7Sc��a <br />IV. TANK OWNER INFORMATION <br />TANK OWNER NAME ala. 1 <br />d6r, oe_,AlZo <br />PHONE 415. <br />'MAILING ADDRESS, <br />� it <br />00 �� �I� %� <br />an. <br />17 icka��saH <br />STATEa18. <br />ZIP CODE 419. <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 UST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) HQ 44- 3 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: El1. FACILITY OWNER � 4. TANK OPERATOR 423 <br />JZ 3. TANK OWNER ❑ 5. FACILITY OPERATOR <br />SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies Only) 406. <br />VII. APPLICANT SIGNATURE <br />CERTIFICATION: I certifv that the information Drovided herein is true, accurate, and in full compliance with legal re uirements. <br />APPLICANT SIGNATURE <br />DATE 424. <br />PHONE 425. <br />r--?- / -/ 0 <br />1 0 Oji i s' -ods Ct/3 <br />APPLICANT NAME (p 'nt) 426. <br />APPLICANT TITLE 427 <br />UPCF UST -A Rev. (1212007) <br />