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 JIft 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE ee 400' <br /> (Check one item only) [1'3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 409' FACILITY ID# t- <br /> (Agency Use Only) <br /> BUSINESS NAME(Swen FACa.RYb kl or DBA-Doing Banns Aa) 3_ <br /> � U v NI Eta �l nNC� <br /> BUSINESS SITE ADDRESS 103, CFFY IN <br /> R ID s . &"I OC-k--t o�, O-A 9f2-07 <br /> FACILITY TYPE1.MOTOR VEHICLE FUELING El 2.FUEL DISTRIBUTION 40J' Is the facility located on Indian Reservation or 495. <br /> �1.FARM 4.PROCESSOR El6.OTHER Trust lands? []Yes o <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 47o7PHONE 409. <br /> tMerrt <br /> MAILING ADDRESS ao9. <br /> (o 4 Q I Fly(fin Nt Ste(• <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4z9-1. PHONE 428-2 <br /> MAILING ADDRESS 429.3 <br /> 6 -,- N s <br /> CITY 4284 STATE 428-3ZIP CODE 4284 <br /> Mo0�r(AI)J � ro� :F c►° <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> ( <br /> MAILING ADDRESS /� 416. <br /> CITY 417 STATE 419. ZIP CODE 419, <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATIO&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. 431_ <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue Permit and send legal notifications and mailings to: ❑ L FACILITY OWNER ❑ 4.TANK OPERATOR 4g <br /> 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406_ <br /> VIL-APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate,and in full compliance with legal requirements. <br /> APPLICAN IGNATURE DATE ( 424 1 PV ^'7 25. <br /> APPLICANT NAME(print) 424 APPLICANT TITLE 3 <br /> we a•+-q rk-P S1N rim <br /> e <br /> UPCF UST-A Rev.(12/2007) <br />