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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK '7-27 "V <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION PV +7 �p`p$ <br /> (Ona fo f ility) / <br /> TYPE OF;�ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE ' <br /> (Check oney) 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs&T FACHJTY 414• FACILITY ID# 1' <br /> (Agency Use Only) 1 1 L7171 24 r <br /> BUSINE �<�"u rt Y N or Doi e %�1 3. <br /> BU$INE,f�Sf ! $ ,4 �� "i 103. CITY 104. <br /> 10�, <br /> FACIL`IITTYY TYTYPI(El//J 1.MOTOR VEHICLE FUELING [12.FUEL DIISTTRIBUTION 403' Is the facility llocated on INian Reservation or 405. <br /> ❑ 3.FARM 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes o <br /> II. PROPERTY OWNER INFORMATION <br /> PPER NAME407. IPHNE 408. <br /> 15 <br /> ' �/� _ _AS <br /> MAILING ADDRESS <br /> 409. <br /> CITY410. 1 STA 411. ZIPCOI,F� ^� ( 412. <br /> III. TANK OPERATOR INFORMATION C(//II�I L✓-, <br /> TANK OPERATOR NAME 428-1• /PHONE 428.2 <br /> l <br /> MAILING ADDRESS 428-3 <br /> CITY 428-4 1 STATE 428-5 ZIP CODE 428.6 <br /> IV. _TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> MAILING ADDRESS 116. <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 154 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST'STORAGE-FEE ACCOUNT NUMBER <br /> TY an HQ 44_ 10101,31 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> NIL PERMIT 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 /> CERTIF certify that the information provided herein is true accurate,and in full com fiance with legal re uirements. <br /> APPLI SI DAIF, 424. 1 X _ az5 <br /> APPLICA t)� 426- APPLJCANT-TITLE M AI J `C%-� azo <br /> UPCF UST-AAm"ffb <br />