Laserfiche WebLink
0 <br /> ~UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> E -OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> 400. <br /> �y} <br /> TYPE OF ACTION ❑ 1.NEW PERMIT Al 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Check one item only) ❑ 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> t. <br /> TOTAL NUMBER OF t�STs AT FACILITY 404' FACILITY ID# <br /> 11 (Agency Use Only) <br /> 3. <br /> BUS SS NAME(Same as FACIIdPY NAME or BBA-Doing Business As} <br /> �' I�/ <br /> l'ifji IU( �. <br /> BUSINESS SITE S 103. CITY oo. <br /> 403. '.:.. 405. <br /> FACILITY TYPE I. TOR VEHICLE FUELING El '_ dian Reservation or <br /> 3.FARM 4.PROCESSOR C] 6.OTHER Trust lands? [I Yes IR No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER <br /> NAME aa� PHONE �4os. <br /> -L <br /> 9 oqS2� <br /> 409. <br /> MAILING ADDRESS <br /> Li 01 C) 412. <br /> CITY 410 STATE 4t1. ZIP CODE <br /> 01 C r <br /> III. TANK OPERATOR INFORMATION <br /> d'g' <br /> TANK OPERATOR NAMEina los VD aza_l. PHONE <br /> a28-3 <br /> MAILING ADDRESS I <br /> �4 ,a`s� <br /> CITY a'-sem STAT +''-s-5 ZIP CODE <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. 1 PHONE <br /> aSSe` F��tr t2�q ) � 3Q-�3y7 og5i <br /> 416. <br /> MAILING ADDRESS <br /> 43-go ReQ-ci, Av2. <br /> an. STATE ats. ZIP 419 <br /> CIT C��33 7�a✓I <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT 5.COUNTY AGENCY ❑ 6.STATE AGENCY a?o. <br /> N <br /> ❑ 7.FEDERAL AGENCY 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> q alt. <br /> TY(TK)HQ _ y 6 3 ( S Call the State Board of Equalization,Fuel Tax Division,if there are questions. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER <br /> 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> tCERT C IO ti t t the informatio rovided herein is true,accurate,and in full com Bance PHolal requirements. ass <br /> NE <br /> LIC G DATE CrS`O at6. APPLICANT TITLE4LIC AME(print) t <br /> asset EIJ�Q.r r� e 0� <br /> UPCF UST-A Rev.(12/2007) <br />