Laserfiche WebLink
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 4M <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE [9 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# _ _ / 1 <br /> (Agency Use Only) 1 <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) <br /> 'A SCO "I/Yl00179 <br /> BUSINESS SITE ADDRESS 13 O 5. W/I- /A),4 y103 CITY OG�! O„ ) 104. <br /> FACILITY TYPE ;W L 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? ❑ 1.Yes R 2.No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> SELL. �P 12`jNEgs IIG ) I(o- 3 <br /> MAILING ADDRESS 4,570 <br /> w. <br /> . v _ 40". <br /> CITY v� 410 STATE 411 ZIP CODE R / 412 <br /> C, <br /> Ec �l q5� SO <br /> III. TANK OPERATOR INFORMATION <br /> 428-1. PHONE 4'8-' <br /> TANK OPERATOR NAME �//q�/' ;.e)j <br /> MAILING ADDRESS 4'8a <br /> l3o S . �, Gson� l•OAY <br /> CITY 428.4 1 STATE 428-5. ZIPCODE 05 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> MAILING ADDRESS 416. <br /> CITY 417 STATE 418. ZIP CODE 419. <br /> E/.vERTA C,A 95 � <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 EQUAIAZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421' <br /> „ VI. P &MIT HOLDER INFORMATION <br /> ✓!r•C 423. <br /> Issue permit and send legal notifications and mailings to: 1.FACILITY OWNER 4.TANK OPERATOR <br /> `r 2 ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406, <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I cern that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424 1 PHONE 425_ <br /> 426. APPLICANT TITLE 427 <br /> APPLICANT NAME(print) _ ��r, <br /> �A KT J. D°� <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org \`,y,n''i <br />