Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK 4�` <br /> OPERATING PERMIT APPLICATION- FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Check one item only) 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 409' FACILITY ID# y 1 <br /> (Agency Use only) J 9 <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) <br /> Q p O <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> FACILITY TYPE M 1.MOTOR VEHICLE FUEL G ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes No 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407, PHONE 408, <br /> O 7 800 <br /> MAILING ADD FSS 4m. <br /> CITY Q 410 STATE 411. ZIPCODE S-tvC • 95o <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1_ PHONE 428-2. <br /> e ( O ) -816 <br /> MAILING ADDRESS 428-3_ <br /> OX 91 <br /> CRY 4394. 1 STATE 425-5. ZIPCODE 4'S-6_ <br /> oc o C 9 5 0 <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE 415. <br /> ( O ) - Boo <br /> MAILING ADDRESS 416. <br /> e <br /> CITY m. STATE 418. ZIPCODE 419. <br /> v S <br /> OWNERTYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY X &NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- O y 1 S 5 1 Q 1 Q� I Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: L FACILITY OWNER "*.ST <br /> OPERATOR J1i <br /> ❑ 3.TANK OWNER E ACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406. <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate and in full compfkage with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. 1 PHONE 425. <br /> APPLICA (pint) 426. 1 APPLICANT TITLE jjjLj 427 <br /> UPCF UST-A Rev.(12/2007)-1/2 www.uuldoee.org <br />