Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM y <br /> UNDERGROUND STORAGE TANK 6O2g /a (/'� <br /> OPERATING PERMIT APPLICATION-FACILITY INFO �, <br /> INFORMATION/.[D 5,3� <br /> TYPE OF ACTION I.NEW PERMIT (One form per facility) <br /> (Check one it only) ❑ 5.CHANGE OF INFORMATION <br /> ❑ 3.RENEWAL PERMIT ❑ 7.PERMANENT FACILITY CLOSURE Ore 1 <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> TOTAL NUMBER OF USTs AT FACILffY 4oI4' FACILITY INFORMATION <br /> C <br /> FACB.Il'Y IDH <br /> BUSINESS NAME(%moe u FAMMY NAMEmDBA- (Agency Use Only) - - 1 'i • �y <br /> OeZ /�U6�3L0 i3 yBt. 1p /lvr`��/J <br /> BUSINESS SITE ADDRESS d,nr�, 3' ((/G6(; <br /> 37,1 F Gt�gBG�i2 iJ r iv(f�' m. CITY <br /> _ / ion. <br /> FACILITY TYPE 13 1. 2.FUEL 1.MOTOR VEHICLE FUELING DISTRIBUTION 403 .S,&ve <<7 ZNl/ <br /> 3.FARM 0 4.PROCESSOR Is the facility located on Indian Reservation or 405. 7(1 <br /> 6.OTHER Trust lands? ❑Yes �No <br /> U. PROPERTY OWNER INFORMATION Id%Qf/zo/c <br /> PROPERTY OWNER NAME /�,, <br /> `44"CefA" ; r # C9Til�e R//✓4'. R L 4m. PHONE <br /> MAILING ADDRESS <br /> 410. � ty <br /> ^'D�� STATE 411. ZIPCODE 412. Ig D1f <br /> TYS-7 <br /> TANK OPERATOR NAME� III. TANK OPERATOR INFORMATION� <br /> 71- 428-1. PHONE- <br /> 128­2 <br /> MAB,ING ADDRESS �qv� (✓rio > �/P��3�0 6 <br /> CITY > 3YI b 42&3 <br /> 1 . ,-? _.A0 438 STATE 428- <br /> n 5 ZIPCODE <br /> -1 4264 <br /> TANK OWNER NAAM�E, ' <br /> IV. TANK OWNER INFORMATION g�S7 ✓ <br /> /� , M <br /> Vr�'t4'�' 4e �- �/I t' a(//j7 414. PHONE` <br /> -� 415. <br /> MAILING ADDRESS <br /> 4 <br /> CITY <br /> 16. <br /> r/r " LG'7�{� 410. STATE _ 418. ZIP `CJ t J' <br /> /"'rte /✓'H/1'" 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY <br /> ❑ 7.FEDERAL AGENCYW_8.NON-GOVERNMENT ❑ 6.STATE AGENCY 420. <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tex Division,if there are questions. <br /> 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 'v1 1.FACILITY OWNER <br /> ❑ 4.TANK OPERATOR 4v <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Oaly) <br /> 406, <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I cerdf that the <br /> APPLICANT$ICr(.Ipinformadon rovlded herein Ia true accurst and in full com lis ace with 1 al r uiremente. <br /> TIJRE <br /> DA azo. <br /> PH�vE J � 3 ' 425. <br /> APP ANT NAME riot) 426. J <br /> 'Ale Q ` APPLIC TA" <br /> 4 r/ r, � D 427 <br /> UPCF UST-A Rev.(1212007) <br />