COMPLIANCE INFO_1997-2012 - Laserfiche WebLink

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d� adj'01 I I•�{ G`1 UNIFIED PROGRAM CONSOLIDATED FORM1� UNDERGROUND STORAGE TANK ae,•�✓ OPERATING PERMIT APPLICATION—FACILITY INFORMATION (One form per facility) TYPE OF ACTION ❑ 1.NEW PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400 (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF LISTS AT FACILITY 404 FACILITY ID 11 _ /{ x _ 2 I (Agency Use Only) •'1 V O V J I I BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3_ o ev BUS NESS SITE ADDRESS 103 CITY 104. ��J(� � Yl�� Lcrll FACILITY TYPE (&I,MOTOR VEHICLE FUELING ❑ 2 FUEL DISTRIBUTION 401 Is the facility located on In ian Reservation or 405 ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes o 11. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE� St� — �� 401 BR ' MAILING ADDRESS 409 CITY7ca TE 411. ZIPCOE 412O I D 2 2---- III. _ -- III. TANK OPERATOR INFORMATION TANK OPERATOR NAME 421-1 PHONE 428-2 7 - 1 I r V 4" (; 6)qj Rua od MAILING A DRESS o / 421-3 w CITY 421-4 STAT 421-5 ZIPCO E 421-6 Ck- � i�� v IV. TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 MAILING ADDRESS 41G i CITY v , 412 STATE 418 ZIPCODE 419 5th WNER TYPE: ❑ 4 LOCAL AGENCY/DISTRI AG ❑ 6.STATE AGENCY 4z. CY 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. V1. PERMIT HOLDER INFORMATION Issue permit and send legal notifications and mailings to: R<FACILITY OWNER ❑ 4 TANK OPERATOR 423 ❑ 3.TANK OWNER ❑ 5 FACILITY OPERATOR 406. SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) VII.APPLICANT SIGNATURE CERTIFICATION:A cqkify thatfie information provided herein is true,accurate,and in full compliance with legal requirements. APPLICANT NAT R DATE 424. PHONEt ei APPLICANT NANM fprint) 411) APPLI NT TITLE "�� til-(•�dC Cid}' �e r UPCF UST-A Rev.(12/2007)