Laserfiche WebLink
,V ,r, .1N3Vi1HVd30 HITV3H <br /> ]VIN3NNOdIAN3 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK C'()7I_�{ <br /> OPERATING PERMIT APPLICATION - FACILITY INFOR1 tx'['�{3 v' <br /> (One form per facility) <br /> TYPE OF ACTION E] 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PER AN I Y RF ; <br /> ri'Av�k nnr ir..+a a.r�or 3.RENEWAL PERM[I 0 6. TEMPORARY FAC•ILI I•Y CLOSURE ❑ 9.TRA �t I -- <br /> I I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY u FACILITY 1D T _ 2 <br /> !:igenn-Use 011141 A. 1� ® � ✓ <br /> BUSINESS((NAME!Sarne a Fctcilirr ,b'' or DRA-Doing Rrrsmess:isl <br /> FSI v i�ll2 6 f 1 �f�ter 1"v 7� <br /> BUSINESS SITE ADDRESS 0' TY 10+ <br /> A- � �++1 � CI -s-n e'v-� <br /> FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING © 2.FU I:l-DISTRIBUTION Is the facility located on Indian Reservation or Ora$ <br /> Cj 3.FARM 0 4.PROCESSOR 6.OTHER Trust lands? ❑ I.Yes A 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 497 PHONE :0 <br /> tT— <br /> � . <br /> w1A1LIVG ADDRESS <br /> CITY ktu STA7"E{ 411 ZIP CODE 'e' <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME ''s PHONE <br /> `1AEL.ING ADDRESS <br /> 4.9 So cnn; <br /> CITY ;=4-4. STATE ;' 1P C ODE xay <br /> S-r- Gtr 1 M'9 2-I <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME PHONE 415. <br /> p {� <br /> F-1 'p -m ill, �l is <br /> 416. <br /> MAIL-1\6-NDDRLS,� <br /> ilTl 417:E I'AT: ris 7.IPCODE aia <br /> 7-L-71 - <br /> OWNER TYPk ❑ 4.LOCAL AGENCY,DiSTR1C l' ❑ 5-COUNTY AGENCY ❑ 6.STATE AGENCY x'01 <br /> ❑ 7.FEDERAL AGENCY S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> ( Q 3 Z 3 S 421 <br /> -j'Y iK}j-1 .��}_ j� Call[he State Board aFEqualization,Fuel Tar Division,if there are questions. <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ I.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPER',ISOR OF DIVISION,SECTION,OR OFFICE(Regr+ired fiw Prrhlic.4gencies Oidl-) 4u6, <br /> VII. APPLICANT SIGNATURE <br /> CE TIF[ TI 1 e Nf that the information provded herein is true,accurate,and in full com liance wikh le ai re uirements. <br /> APPL AN"I N R DATE- a'4 PHONE <br /> I-1Z- )'3 { )R✓� <br /> APPLIC'A NAME(grin �'a APPL.ICANT'1"[TLE Ac7 <br /> R � <br /> L'PCF UST-A Rev.(17/2007)-112 www.unidocs.org <br />