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UNIFIED PROGRAM CONSOLIDATED FORM f ref t1 <br /> UNDERGROUND STORAGE TAN <br /> OPERATING PERMIT APPLICATION- FACILITY INFORM OK4�"q <br /> (One form per facility) <br /> TYPE OF ACTION ❑ I.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 414. FACILITY ID# <br /> 14 (Agency Use Only) J <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> 60 y N TizV Iq -2.T (;_4 S 6C I`ov <br /> BUSINESS SITE ADDRESS 103. CITY A <br /> 3 z 3 �e�s M �� T� y <br /> FACILITY TYPE ,� 1.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? ❑ 1.Yes R3 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME407 PHONE 408. <br /> PQ5HP1NPF-k S>A/s H ku�D �'P S��1s'N Tst ivj�- sS9 � -TSZ -i-igeS <br /> MAILING ADDRESS 1�1£rT 409. <br /> CITY410. STATE 411. ZIP CODE 412. <br /> 3 -L -73 CA - &73 z_73 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 423-1. PHONE 428-2. <br /> "r'14if4N3-1T 51�vIP SAN-DH� <br /> MAILING ADDRESS 428-3. <br /> CITY <br /> az8 a. STATE 428-5. ZIP ODE 428-6. <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> JAS <br /> MAILING ADDRESS 416. <br /> CITY 417 STATE 418. 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, .� �' 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: ❑ L FACILITY OWNER 4.TANK OPERATOR 423. <br /> ❑ 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 certify that the information provided herein is true accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 425. <br /> . �� 4-!? - o P zap ) bc� ?-- <br /> APPLICANT NAME(print) INS/..� S�-�� L t . ' <br /> 426. APPLICANT TITLE 427 <br /> `-FP-�ry TIT S 4 L( 13(1S1 N£.SS 00-AJ-Ek <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org r g <br /> y 6:r Bat i <br />