Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One Ibnn per facility) <br /> TYPE OF ACTION /�1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Cheek one item only) ❑ 3 RENEWAL PERMIT El 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 494' FACILITY ID k <br /> Mvemry Use Only) <br /> BUSINESS NAME(swe.s FAca.ITY NA or!)M-Doing Bm nss As) 3 <br /> �'qST l= <br /> BUSINESS SITE ADDRESS 103. CITY m4. <br /> 2'l W E'4i-Ir n <br /> FACILITY TYPE ® I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is rhe facility located on Indian Reservation or 406' <br /> 3.FARM 4.PROCESSOR 6.OTHER Trust lands? ❑Yes JA No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 40. PHONE aoa. <br /> MAILING ADDRESS y09 <br /> O C ✓176 rt e GlY11j�f�`�Ul Q Ovv� <br /> CITY 410. STATE 411- ZIPCODE 412, <br /> Skocw}on C -A 17X212 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 429-2 <br /> Shit <br /> MAILING ADDRESS 42 3 <br /> '39J7 2i cimo <br /> CITY 4284 1 STATE 428-5 1 ZIPCODE 4294 <br /> 5-�oc V-to tem <,A 95212 <br /> W. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 414. <br /> Scar~ e+5 0-;n- qGv e ( ) <br /> MAILING ADDRESS 418_ <br /> CITY 417. 1 STATE 418 1 ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4m. <br /> ❑ 7.FEDERAL AGENCY ® 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 Equalization,Fuel Tax Division,ifthere are questions. 421' <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ® 1.FACILITY OWNER ® 4.TANK OPERATOR 415 <br /> m 3.TANK OWNER 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406' <br /> VH.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate,and in full compliance with 1e aI requirements. <br /> APPLICANT SIGNATURE DATE 424 PHONE vs. <br /> APPLICANT NAME(print) 926 APPLICANT TITLE uo <br /> SUI< I1w1Iv7Jl�R SlNC.1/ U� � I' <br /> UPCF UST-A Rev.(12/2007) <br />