BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

.s UNIFIED PROGRAM CONSOLIDATED FORM'/,Y- -_ UNDERGROUND STORAGE TANK n r _� f 6. OPERATING PERMIT APPLICATION — FACILITY INFO TION /31 P (One Corm TYPE OF ACTION ❑ 1. NEW PERMIT5. CHANGE OF INFORMATION (Check one item only) ❑ 7. PERMANENT FACILITY CLOSURE ❑ 3. RENEWAL PERMIT ❑ G TEMPORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT 2v1gt, IvutwsE U' LISTS AT FACILITY 4",FACILITYIDF �'�s O (Agency Use Onfy) (,/ 3 $ S BUSINESS NAME (=eu FAD ITY NAhfficrDBA-DoinaaumcssAs) �. S AQ- BUSINESS SITE ADDRESS 500 — ID42 p FACILITY TYPE ❑ 1. MOTOR VEHICLE FUELING 2. FUEL DISTRIBUTION ility located on Ind? Reservation or 4os.3. FARM ❑ 4. PROCESSOR ❑ 6.OTHER ds? ❑ Yes L NoPROPERTY 4407.pHONE OWNER NAME 4os. Te§oro Sierra Properties, LA201 '-3y 3450 South 344th Way, Sui 4a9. :MAIELUlNGDDRESS Auburn, WA 98001-5931 ZIP CODE 412. TANK OPERATOR NAME PHONE 428-2 MAILING ADDRESS Tesoro West Coast Company, LLC - 3�f 3450 So. 344th Way, Suite 201 4383 CITY Auburn, WA 98001-5931 28-1 ZIP cope 42as TANK OWNER NAMES"-� 4t4. PHONE MAILINGADDRESS Tesoro West Coast Company, LLCM $ 3 415. 3450 So. 344th Way, Suite 201 91` CITY Auburn, WA 98001-5931 ZIP CODE 419. OWNER TYPE: ❑ 4. LOCAL AGENCY/DISTRICT ❑ 5. COUNTY AGENCY ❑ 6. STATE AGENCY 420. ❑ 7. FEDERAL AGENCY. NON-GOVERNMENT a TY (TK) HQ 44- Call the State Board of Equalization, Fuel Tax Division, ifthew are questions. 421. Issue permit and send legal notifications and rtmilings to: ❑ 1. FACILITY OWNER ❑ 4. TANK OPERATOR ext M3. TANK OWNER ❑ 5. FACILITY OPERATOR SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies Only) T% CERTIFICATION: I cert:ify that the information provided herein istrue, accurate and in full Com Bance with liege] requirements APPLICANT SIGN TURF DATE Jig., i�l 424. PHONE pp p us. APP ANT NAME (pnn0 4 Manager En ironmffb & Bud$ T TITLE ILZ)Q% `� o O O 417 UPCF UST•A Rev. (122007)