Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATIO (n/ <br /> M per facility <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION )j7.PERMANE T FA ILITY CLOS 400. I '3 <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT 3 <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF UST T F CI 404 FACILITY ID f♦ ! e _ 11 O _ <br /> (Agency Use Only) r !`1 C! <br /> BUSINESS NAME(5'me�Fn yTr�.nt.� A- ing Busieess As) iO3 � 02 7 /b O() <br /> SS 3- <br /> BUSINESS SI ADDRECITY (J t°e. <br /> Oo Fro �A .P MA N �46C <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION Is the facility locatedon Indfaq Re servation or 40.❑ 3.FARM 114.PROCESSOR .OTHER Trust lands? ❑Yes o <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER N E 407 PHONE 418. <br /> I rteI S-1*4-e s Z y $ - 3°ISo <br /> 409_ <br /> MAILING ADDRESS <br /> CITY <br /> 0 , Sax ZoLi <br /> m. <br /> 4STATE 4°. ZIP CODE � 412,z. <br /> S f 6G 4z +1-o S ;b ' <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> 41�b VCS ) <br /> MAILING ADDRESS 428a <br /> CITY 428.4 STCODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE 415 <br /> MAILING ADDRESS 416. <br /> CITY 4iz STATE 4is. ZIP CODE 419. <br /> OWNER TYPE; ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY 6.STATE AGENCY 4za <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44_ Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421' <br /> VI.PERMIT HOLDER INFORMATION <br /> 423 <br /> Issue permit and send legal notifications and mailings to: F1 1.FACILITY OWNER El4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406 <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) . <br /> U R-Kk ) b <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full eom liance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 425. <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> UPCF UST-A Rev.(122007) <br />