Laserfiche WebLink
107 <br /> IV <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One forth per facility) <br /> TYPE E__ACTION ❑ I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE ' <br /> (Check one item only) X3.RENEWAL PERMIT ❑ <br /> ❑ 6.TEMPORARY FACILITY CLOSURE 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs T FACILITY aoa. FACILITY ID# <br /> (Agency Use Only) <br /> BUSINESS NAME(Same.FACILMY NAME or DBA-Doing Business As) 3. <br /> je_& T7"( Eor74-n! Ce-t-W,611) <br /> BUS e:)ESS SITE ADD�SS k,G 7-TLC-� ` L11) 103. CITY WL7•� 9!S;2--VL 104. <br /> FACILITY TYPE )9,1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 05' <br /> 3.FARM El 4.PROCESSOR 6.OTHER Trust lands? ❑Yes ❑No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTYffNER NAME 407• PHONE 408. <br /> -( !bbmt4PD I A,,& <br /> mAiLwaADDass 409. <br /> 410• STATE 411• ZIP CODE 41' <br /> III. TANK OPERATOR INFORMATION <br /> TANK YPERATOR NAME 4'-8-1. PHONE 4+„g-2 <br /> v i"D61 Q S�Q-f (Z�S ) 333 D3 0 <br /> MAILING ADDRESS 428-3 <br /> COPYr i < STATE_ _ a s ZIP CODE��Z� T2_87- <br /> /u✓>1., IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME414. PHONE 415. <br /> MAIL�3ss , / u S� �1� 416. <br /> C / !" 419. ZIP CODE Ts26 47. 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY 19 9.NON-GOVERNMENT <br /> . BOARD OF EQ ST STORAGE FEE ACCOUNT NUMBER <br /> TY(TIC)H 3 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421• <br /> VI.PERMIT HOLD TION <br /> Issue permit and send legal notifications and mailings to: bf TANK OPERATOR 423 <br /> �R ❑ RATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) �' <br /> VII.APPLICANT SIGNATURE - <br /> CERTIFICAT N: I cern tha a infWn4fion provided herein is t m accurate,and in full compliance with legal requirements. <br /> APPLICANT I AT� DATE ` /r 424 PHONE 333 03jW <br /> APPLICAIT PAME(print) 42b• APPLICANT rrLE tl 4-77 <br /> v r��� ��tI ©�-► rte. ' <br /> 1� <br /> UPCF UST-A Rev.(12/2007) ► { . t,r <br />