COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

0 0 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUNDSTORAGETANK OPERATING PERMIT APPLICATION-FACILITY INFORMATION (One foam per facility) TYPE OF ACTION ❑ 1.NEW PERMIT ❑ S.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 40o. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF USTs AT FACILITY °04' FACILITY ID# _ _ 1. (Agency Use Only) BUSINESS NAME(Same w FACMIFY NAME orDBA-Wing Bmin®e As) 3. BUSINESS SITE ADDRESS 103. CITY 104 FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. ❑ 3.FARM ❑ 4.PROCESSOR 0 6.OTHER Trust lands? ❑Yes ❑No H. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407. PHONE 408. MAILING ADDRESS 4097 CITY 410. 1 STATE 411 ZIP CODE 41-2- III. TANK OPERATOR INFORMATION TANK OPERATOR NAME 428-1, PHONE 428.2 MAILING ADDRESS 428-3 CITY 4294 1 STATE 428-5 ZIP CODE 428fi IV. TANK OWNER INFORMATION TANK OWNER NAME 414, PHONE 415. MAILING ADDRESS 416. CITY 417. STATE 418, ZIP CODE 419. OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. VI.PERMIT HOLDER INFORMATION Issue permit and send legal notifications and mailings to: ❑ L FACILITY OWNER ❑ 4.TANK OPERATOR 423 ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 4a6. VII.APPLICANT SIGNATURE CERTIFICATION: I certify that the information provided herein is true accurate,and in full compliance with legal requirements. APPLICANT SIGNATURE DATE 424 PHONE 425. APPLICANT NAME(print) 426. APPLICANTTITLE 427 UPCF UST-A Rev.(12/2007)