Laserfiche WebLink
av <br /> V s� EULtIVED <br /> MAR 1 0 2016 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK1Nf ENT <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTIONI.NEW PERMIT El ❑ 7.PERMANENT FACILITY CLOSURE 5.CHANGE OF INFORMATION 400• <br /> (Check one item only) ❑ 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAJ_N-Uk1BER OFF U�,STs AT FACILITY 464. FACILITY ID# 1 <br /> C,2 ;7-49 e-' (Agency Use Only) —BUSINESS NAME(Same as FACMXrY NAME or DBA—Doina Buse <br /> /—? �-�F2 7'/ <br /> BUSINESS SITE ADDRESS j 103�, CITY�v 0+ <br /> FACILITY TYPE ❑ MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 401 Is the facility located on Inch eservation or 405- <br /> 3.FARM Ej 4.PROCESSOR 6.OTHER Trust lands? ❑Yes No <br /> IL PROPERTY OWNEII-INFORMATION <br /> PROPERTY OWNER NAME _� X07. PHONE 41. <br /> 2MILIN0 ADDRESS � � � 409_ <br /> TY 41°. STATE 411. ZIP CODE 411 <br /> III:. TANK OPERATOR INFORMATION <br /> TANK OPERATOR LL l AME 429-1. (HONEZG� 1 428-2 <br /> 1 <br /> 1-2 <br /> MAILING ADDRESS ,e 429-3 <br /> CITY 428 STATE 428-5 ZIP CODE 42" <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. 1 PHONE _ _ 415. <br /> c _ice <br /> A <br /> D <br /> CITY 417. 1 STATF41s. ZIP CODE _ 41v- <br /> C� —C 3 <br /> OWNER TYPE: 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> (� 7.FEDERAL AGENCY 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. 471 <br /> VI PERMIT HOLDER INFORMATION <br /> 471 <br /> Issue permit and send legal notifications and rnailings to: ❑ FACILITY OWNER ❑ 4.TANK OPERATOR <br /> tk TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406 <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I pWtify that the information provided herein is true,accurate,and in Cull gompliance with legal requirements. <br /> 47PHO / 425 <br /> APPLICANTSIGNDATE / 4. <br /> APPLICAN NA � � 4z6. App�c �� � � 427fn[ v <br /> UPCF UST-A Rev.(1212007) <br />