Laserfiche WebLink
t" l' ►� <br /> UNIFIED PROGRAM CONSOLIDATED FORM r10tD p y&*0+D - <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 400. <br /> (Check one item only) b 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OTs AT FACILITY 404. FACILITY ID# <br /> (Agency Use On <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Do in us /iiness As) 3. <br /> V A <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> o? /YI N s if1z�7�G9 <br /> FACILITY TYPE1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ❑No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNElAME 407. PHONE _ 408. <br /> � <br /> MAILING ADDRESS 409. <br /> CITY 410. STATE 411, ZIP CODE 412. <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1PHONE 428-2 <br /> 2vo �v «_ <br /> "LING ADDRESS 428-3 <br /> CITY 4284 STATE 428-5 ZIP CODE 428-6 <br /> O <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> S Be) I ( ) <br /> MAILING ADDRESS 416- <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 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: Erl.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <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 /> CER ICATION: I certify that the information provided herein is true accurate,and in full compliance with legal requirements. <br /> APPLICA ATURE DA�//� aza. PHONE/ �_1,53 <br /> / azs. <br /> APPLICANT NAME(print) � t� 4z6. APPLICANT'TIT%L`E` F, 427 <br /> lL- <br /> UPCF UST-A Rev.(12/2007) <br />