Laserfiche WebLink
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 ooe item ovy) 10 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY/ 400' FACR.ITY ID# <br /> (Agency Use Only) <br /> 3. <br /> BUSINESS AM/E(svM:?Cwry NAME or DeA-Deft emi.As) <br /> Ti£ F 7( Ii S ) / <br /> BUSINESS$ITE ADORES$ 103. CITY 1w. <br /> FACILITY TYPE PRI.MOTOR VEHICLE4033. <br /> FUELING ❑ 2.FUEL DISTRIBUTION Is the facility located on Indira Reservation or <br /> 3.FARM 0 4.PROCESSOR 0 6.OTHER Trust lands? ❑Yes Flo <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4m. PHONE 4(%.Fc� 8av 3r��soo <br /> MAILING ADDRESS <br /> 3 / --/ 1sf °/ljv fid¢ Sm 2S6/z <br /> CITY <br /> ale. 1 STATE 411. 1 ZH'CODE412. <br /> /'C"ez'awo vii- Z3 _30 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4' PHONE 428-' <br /> 43SJ <br /> MAILING ADDRESS <br /> 76!/ fo <br /> CITY 4284 1 STATE 4�5 1 ZIP CODE 4?sa <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 413. <br /> 11�s.25 s (gov ) 3r3- �so � <br /> 41e. <br /> MAILING ADDRESS <br /> //Z G1 >t yf-6!2 <br /> Com. a1r. 57AjF,� 418. ZEPCOpE3�3J 4M <br /> esti(Z. "/4 i(( GG <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4aa <br /> ❑ 7.FEDERAL AGENCY D3 S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY( K)HQ 44_ 10 Call the State Board of Equalization,Fuel Tax Division,if there arc questions. 431. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 1.FACILITY OWNER 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 4on. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFIC ce t e information provided herein is true accurate,and in full rnm Bance with lezal requirements. <br /> APPLICA SIGN U DATE 424 PHONE 4'-3' <br /> APPLICANT NAME t) 4M. APPLICANTTJ 'LE <br /> urCd� / �+ <br /> UPCF UST-A Rev.(12/2007) <br />