Laserfiche WebLink
pwr <br />.s <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br />(One form per facility) <br />TYPE OF ACTION ❑ I. NEW PERMIT ❑ S. CHANGE OF INFORMATION 7. PERMANENT FACILITY CLOSURE 400. <br />(Check one it.. only) ❑ ; RENEWAL PERMIT [16. TEMPORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT <br />L FACIUrY INFORMATION <br />TOTAL NUMBER OF USTs AT FACILITY 04. <br />FA IDN <br />/+ <br />A <br />t <br />sn;,UY <br />(Agertey Use Only) <br />BUSINESS NAME (gone u FACILITY NAFSE or DBA - Ming Beuneo As) <br />4� <br />s rs St< Ru, fr 99 0. S rek �%, E <rfc✓. F <nr« AM-ev For; / •� <br />BUSINESS SITE ADDRESS 10 <br />CITY IN. <br />Lt. <br />c f6n <br />FACILITY TYPE US L MOTOR VEHICLE FUELING [12. FUEL DISTRIBUTION <br />Is the facility located on Indian Reservation or +os. <br />3. FARM ❑ 4. PROCESSOR ❑ 6. OTHER <br />Trust lands? ❑ Yes ,K No <br />H. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407. <br />PHONE 408. <br />Ce/f sp • S4`fir d? C46A0f�+i4 <br />y S-LJ74G <br />MAILING ADDRESS 409, <br />B.S.f M S¢/<c f o f -Il t Ago <br />CITY - 410. <br />STATE 411. <br />ZIP CODE 412. <br />1 <br />III. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 428-1. <br />PHONE 428-2 <br />errhtrAli" Co FG4. <br />/9 <br />MAILING ADDRESS 428-3 <br />CITY _ 4284 <br />STATE 428-5 <br />ZIP CODE 42M <br />Q <br />,7 1 <br />IV. TANK OWNER INFORMATION <br />TANK OWNER NAME - - - 414. <br />PHONE 415. <br />e f • % O f1r Ce�/ d/w /G <br />SSi� - T7J� <br />MAILING ADDRESS 416 <br />sr 'Pao <br />CITY 411 <br />STATE 41 e. <br />ZIP CODE 419. <br />r<1ro 1 <br />C fig <br />?J 7-:9- <br />OWNER TYPE: ❑ 4. LOCAL AGENCY/DISTRICT ❑ S. 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_ )CE /''/ .0 ••T 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: I. FACILITY OWNER ❑ 4. TANK OPERATOR 435 <br />❑ 3. TANK OWNER ❑ 5. FACILITY OPERATOR <br />SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies Only) 408. <br />< Go r <br />VII. APPLICANT SIGNATURE <br />CERTIFICATION: I certify that the information provided herein is true accurate, and in full compliance with le al re uirements. <br />APPLIC NT SIGNATURE <br />DATE 424 <br />PHONE <br />4iG Sri- rAPPLICANT <br />NAME(print) 426. <br />]425. <br />A/P�PLICANT TITLE <br />UPCF UST -A Rev. (12/2007) <br />