Laserfiche WebLink
04 <br /> IED PROGRAM CONSOLIDATED FO <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION 29 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION400. <br /> (Check one item only) ❑ 7.PERMANENT FACILITY CLOSURE <br /> El3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. <br /> FACILITY <br /> 3 I (Agency(Ise Only) �J <br /> BUSINESS NAME(Same m FACILITY NA or DBA-Doing liusinm As) 3. <br /> A LL <br /> BUSINESS SITE ADDRESS 1m. CITY 104. <br /> S00 % �k Loa : <br /> FACILITY TYPE ❑ L MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' is the facility located on Indian Reservation or 4e5. <br /> ❑ 3.FARM ❑ 4.PROCESSOR X 6.OTHER Trust lands? ❑Yes Al No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> LL 3(49 ams, <br /> MAILING ADDRESS 409, <br /> � 0 100 <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> OSZSi <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> A ewt.`,r `Ax-jx LL(- ( 9 ) 3 %-9000 <br /> MAILING ADDRESS 428-3 <br /> Soo Ra <br /> CITY 4284 1 STATE 428-5 ZIP CODE 4284 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> LLL (109 ) 3(og 8Z5S <br /> MAILING ADD SS 416. <br /> C> koo <br /> CITY 4v. STATE Ota. ZIP CODE 419, <br /> L A qS Z5a <br /> OWNER TYPE: - ❑ LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY f9 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 /> Issue permit and send legal notifications and mailin s to: 423 <br /> p ga g ❑ 1.FACILITY OWNER �4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATI N: I certify that the information provided herein is true accurate and in full compliance with legal requirements. <br /> APPLICAM ATURE ✓ DATE 424. PHONE 425. <br /> S Z zo I- 8o II <br /> APPLICANTNAME(print) 426. pppLICANT LE 4n <br /> AovDw W• M1oC� EIlS Poc.:l;�;es �••� • Ma l <br /> UPCF UST-A Rev.(12/2007) <br />