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UNIFIED PROGRAM CONSOLIDATED FORM E 111 I <br /> UNDERGROUND STORAGE TANK l <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ S.CHANGE OF INFORMATION V7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one Hent only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY FACILITY ID!t F11 <br /> _ 1 <br /> a (Agency Use Only) 0 <br /> USI ES AME(Same as ac!ity ante cr D -Doing Business As)� 3 <br /> rfc t D <br /> USINESS SITE ADDRES 1 14 103. CITY 104. <br /> FACILITY TYPE ElL MOTOR VEHICL FUELING [:12 EL DISTRIBUTION 403' Is the facility located on India Reservation or cos. <br /> [-13.FARM [14.PROCESSOR 6.OTHER Tnlst lands? ❑ 1.Yes 2.No <br /> 1.`'PROPERTY OWNER`INFORMATION <br /> FP1yTIVNER NAME 407. PHONE Hoa. <br /> Vdoo <br /> MAILING ADDR S L 409' <br /> 7 �• <br /> CITY 410- STATE alt•FZIPDE 412. <br /> � 511 a <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPE TOR NAME /i 428.1. PHONE 423.2. <br /> ate ) t41 --i A,, <br /> MAILING AD1))2E5S � � � t5 rIc 428-3. <br /> 428.4 STATE 428.5• ZIP CODE 428s. <br /> IV. TANK OWNER INFORMATIONI. <br /> ANKO, RNAME 414. PHONE 415, <br /> i N1 J b NO ) r <br /> 'rvfAlLINGADDRESS 416. <br /> cl)-o t <br /> CITY �_ 417. STATE 418. ZIP CODE 419. <br /> CA <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT E❑ 55 BOUNTY AGENCY [16.STATE AGENCY 420• <br /> ❑ 7.FEDERAL AGENCY U 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(-tK) Q 44- Call the Stat-- aru o;Equalization,:•uei TaxDiviicn,ii facie ar- .�::stions. 421. <br /> I-I <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 9;K1.FACILITY OWNER El4.TANK OPERATOR 423' <br /> ❑ 3.TANK OWNER ❑ S.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 496. <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate and in full com liance with le al requirements. <br /> AP IGNATU DATE 424. PHONE 428. <br /> /mac-' 1 6 20 Zoe St3 �`�.3'C�33 <br /> AP ANT NAME(print) 426- APPLICANT TITLE 427 <br /> s T Q r <br /> UPCF UST-A Rev.(1212407)-112 If Inv.unidocs.arg <br />