Laserfiche WebLink
4 001194 �f <br /> U <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <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 4W <br /> (Caent one/rem only) ❑ g RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 401' 1 FACILITY ID e _ I <br /> (Agency Use Only) - !' <br /> BUSINESS NAME(Same as Fadllly Name or DBA-Ibing Business As) � �O©/�z� I. <br /> BUSINESS Sp'EADDRESS SO.+ gym. CITY e'rf mo. <br /> F (C+ <br /> AILrry TYPE )k'1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 4D' 1s the facilitylooted on I ion Reservation or <br /> 3.FARM Q 4.PROCESSOR Q 6.OTHER Trust lands? ❑ 1.Yes 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME am. PHONE 4oe.- <br /> r � 3 - <br /> MAILING ADD SS 40. <br /> L <br /> C Oto, 1 STATE 411. 1 ZIP CODE az <br /> aw q 502 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 42x•1. PHONE 428-Z <br /> S <br /> MAILING ADDRESS 4za-5. <br /> CITY 42 1. 1 STATE 411-1 ZIP CODE 4U4. <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME Ota PHONE 415. <br /> MAILING ADDRESS aia <br /> CITY 417. 1 STATE 418. ZIPCODE 419. <br /> OWNER TYPE: [14.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4R0. <br /> ❑ 7.FEDERAL AGENCY CK8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 10 13 1 S - Cali the State Board of Equalization,Fast Tax Division,if there are questions. 421' <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: A 1.FACILITY OWNER [14.TANK OPERATOR 423. <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Bequbed for Public Agencies Only) 40. <br /> VII.APPLICANT SIGNATURE <br /> CERTMCATION: I cerdly that the information provided herein Is true accumte.and to fail emnisliance with legal requirement& <br /> APPLICANT SIONA --- DATE 4m. PHONE .tu <br /> k <br /> APPLICANI'N 't) 426. APP CANT TITLE '„n <br /> /V <br /> UPCF UST-A Rev.(12/ZW7) 12 www.mldocs.org <br /> t d <br /> completed <br />