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232 <br /> n'Wj ej 26(1 Q <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION 19 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <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' FACILITY ID# <br /> 41 (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) s <br /> Er n qCt.A <br /> BUSINESS SITE ADDRESS 103. CITY 104 <br /> 45100 61 s / II <br /> FACILITY TYPE 9-1.MOTOR VEHICLE FUELING [12.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405 <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes 2.No <br /> U. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NA 407 1 PHONE 408 <br /> 44 <br /> MAILING ADDRESS 409 <br /> CITY 410 1 STATE 411. ZIP CODE 41'_ <br /> z- do � 9S,33 <br /> III. TANK OPERATOR INFORMAT ON <br /> TANK OPERATOR NAME nn 428-1 ONE 428-' <br /> MAILING ADDRESS 428-3. <br /> p <br /> CITY <br /> 4284- STA 428-5. ZIP CODE 428.6. <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME �1 414. PHONE 415. <br /> MAILING ADDRESS 416. <br /> PO <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> t� a 9s"33o <br /> OWNER TYP : ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY 2�$.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44_ 1 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 131 <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER 13-4.TANK OPERATOR d_3 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) f-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 /> APPLICANT3GN#111RE DATE 424. PHONE 425 <br /> PLICANT NAME(print) 426. APP�LICANT TITLE / 427 <br /> / <br /> UPCF UST-A Rev.(1212007)-U2 www.unidoes.org <br />