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WiffIED 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 400. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I FAGILITY:INF®RMATION TOTAL NUMBER OF USTs AT FACILITY 404. r t. FACILITY ID# (Agency Use On BUSINES NAME(SameasFACHMNAMEorDBA-DoiingBusinessAs) 3. ACL Toffigh C®; `. BUSINESS SITE ADDRESS 1 103. CITY 104. a-- cmf Ce.A FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2. EL DISTRIBUTION 403' Is the facility located on Indian Reservation or 405. ❑ 3.FARM El 4.PROCESSOR 6.OTHER Trust lands? ❑Yes No PROPERTY OWNER INF ON PROPERTY OWNER NAMEam• PHONE 408. ol onnoto rf) Tw_ ao MAILING ADDRESS f 409. I f. CAr CITY 410. STATE 411• ZIP CODE 412. III. TANK,OPERATOR INFORMATION TANK OP RATOR NAME 428-1. PHONE 428-2 MAILING ADDRESS 428-3 t)CL-, em . CITY 4284 STATE 428-5 ZIP CODE 428-5 IV.:TANK OWNERINFORMATION TANK OWNER NAME 414. PHONE 415. Am TO MAILING ADDRESS ® ' n n 415. CA Jl, M CITY 40. STATZ 418. ZIP CODE 419. C OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. ❑ 7.FEDERAL AGENCY 8.NON-GOVERNMENT V. BOARD OF.EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER _. TI'(TK)HQ 44- 0 "7 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421' VI.PERMIT ROLDER INF®RMATION l Issue permit and send legal notifications and mailings to: 10 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. VII.APPLICANT SIGNATURE CERTIFICATION: I certify that the information provided herein is tree accurate,and in full com fiance with legal requirements. 'i APPLICANT it SIGNATURE DATE za• PHONE � 425.`'(9-4 1 0-to I2_12W AZ "q APPLICANT NAME(print) 426. APPLICANT TITLE 427 icnel40117, N�1 UPCF UST-A Rev.(12/2007)