Laserfiche WebLink
/o�i rat - <br />UNIFIED PROGRANI CONSOLIDATED FORM <br />F� <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br />(One form per facility) <br />JOu <br />TYPE Of: ;\CIION ❑ I. NEW PERMIT ❑ RANGE OF INFORMATION ❑ 7. PERMANENT FACILfIY CLOSURE <br />(Cheek one item only) .0 3. RENEWAL PERMIT ❑ (i. TEMPORARY FACILITY CLOSURE ❑ 9. T"RANSFER PERMIT <br />1. FACILITY INFORMATION <br />'TOTAL NUMBER OF UST's AT F'ACILI'TY -114 <br />FACILITY ID # <br />(:!geney Use Onlig <br />BUS IN FSS NAME (S,nw u FACILITY NAM or Dna - tkma uLLcnws .tet <br />ra S of as - <br />BUS ESS SITE ADDRESS 10.1 <br />?ZtIt. kk-f , r��Lfa•� G4 Sz0/ <br />CITY 10' <br />e j <br />FACILITY TYPE ❑ I. MOTOR VEHICLE FUELING 02. FUEL DISTRIBUTION <br />Is the facility located on Indian Reservation or as <br />❑ 3. FARM ❑ 4. PROCESSOR 6.OTI IFR <br />Trust lands" ❑ Yes No <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME_ 707Pl <br />IONS Jos <br />moo's Z its <br />MAILING ADDRESS 409 <br />% P, / <br />TTY tJ� 710 <br />STATE 711 <br />ZIP CODs 712 <br />,t <br />a• a <br />III. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 428-1. <br />PHONE =" = <br />S Z k <br />1 ( ? 3 ) P ? - <br />MAILING ADDRESS '*'1 <br />,d e -r (t <br />CITY 1=s 1 <br />STATE 7=" ` <br />ZIP CODE =" " <br />,�� <br />N J <br />p •2o Y� <br />N. TANK OWNER INFORMATION <br />TANK OWNER NAME -114, <br />Z <br />PHONE 415, <br />1 473 ) � ?- 3FYJ <br />o- S' to <br />MAIL NGrr DRESSj Jt°' <br />f�,- e W �" <br />CITY 717STATE. <br />71R <br />ZIPCODE Jln <br />0010 <br />OWNL!RTYPE: ❑ 4. LOCAL AGENCY/DISTRIC"r ❑ i, COUNTY AGENCY ❑ 6. STATE. AGENCY 4217 <br />❑ 7. FEDERAL AGENCY B 8. NON-GOVERNMENT <br />V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) HQ 44- 1 1 Call the State Board of Lqualiration, Fucl Tax Division, if there are questions. 421 <br />VI. PERMIT HOLDER INFORMATION <br />Issue permit and send legal notifications and mailings in: ❑ I. FACILITY OWNER ❑ TANTE OPERATOR 421❑ <br />3. TANK OWNER kFACILITY OPERATOR <br />Jao. <br />SUPERVISOR OF DIVISION, SECTION. Olt 01 -1 -ICL (Required For Public Agencies Only) <br />VII. APPLICANT SIGNATURE <br />CERTIFICATION: I certify that the information provided herein is true, accurate, and in Full cont tliunce with legal re uirentenvi. <br />A P 'AN GNATURE <br />DATF.U 7=7 <br />0 ^� l ' d <br />PHONE 7=` <br />t 77a) ? -,77-17 ').S <br />NAME• (print) •1]b. <br />APill-I ANT TITLE 4> <br />kAP'LICANNT <br />UPCF UST -A Rev. (12/2(107) <br />�� <br />L3 <br />