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UNIFIED PROGRAM CONSOLIDATED FORM , <br /> UNDERGROUND STORAGE TANK <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) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' 1 FACILITY ID# _ 7 1 rJyj <br /> *- :2- t' <br /> (Agency Use Only) <br /> ilk/THESS �(Same�FACII.irTI�jAME,orDBA-Doing Bilin As � � 3 <br /> 4//I//''���K��//jT�� 'R��//'/S'flSAyr./ W �..f'/ <br /> BUS ��ITE��r`� ✓` , 1� ��'" WN I03. C! 04. <br /> FACILITY TYPE I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Ind* Reservation or 405. <br /> El 3.FARM 4.PROCESSOR [16.OTHER Trust lands? ❑Yes �No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> I EL • N fh/61�� 2-01I (oDq -q'7OD <br /> MAILING ADDRES 409• <br /> L-�4a6 PIC, AYI-:5r-Jl l E <br /> CIC,r ' 410• STATE_ att. ZIP CQDE ati. <br /> NV: IIT. TANK OPERATOR(INFORMATION(�✓-�L7l,J, <br /> TANK OPERATOR NAME � 428-1. PHONE 428-2 <br /> PA-N I �L. J N AvvKa G- <br /> MAILING ADDRESS 425-3 <br /> CITY 4284 1 STATE 428-5 ZIP CODE 428.6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME ala. PHONE 415. <br /> MAILING ADDRESS 416. <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY ago. <br /> ❑ 7.FEDERAL AGENCY k 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 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: 8 1.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 /> TIFICATION: I certify that the information provided herein is true accurate,and in full compliance with le al requirements. <br /> CANQSIG AIS TURF DATE?--2^ 1 � 424. PHONEPCktj0q-e1 4q,1D <br /> APPLICANT NAME(prin 4'-6• APPLICANT TITLE 4'-7 <br /> bpi� I N?/ON E ovj Nin?- <br /> UPCF UST-A Rev.(12/2007) ., <br /> rF <br />