Laserfiche WebLink
r <br /> P"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 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY404' FACILITY ID# 1' <br /> ��C) (Agency Use Only) YJAI Q Z <br /> BUSINESS NAME(Same as FACQ rrY NAME or DBA-Doing Business As) r / I 3 <br /> BUSINESS SITE ADDRESS /O�•. Y L)S_/ )A(�/ � 103. CITY �� toa. <br /> FACILITY TYPE A 1.MOTOR VEHICLE FUELING J'r❑ 2.FUEL DISTRIBUTION 403• Is the facility located on Indian Reservation or 405. <br /> 3.FARM 4.PROCESSOR 6.OTHER Trust lands? ❑Yes ANo <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 'Of6 60' 408. <br /> 1/v n �� /� 4� PHONE /� 6 <br /> MAILING ADDRESS �/ �l 409• <br /> Sa I;u�e <br /> CITY 410• STATE 411• ZIP CODE 412. <br /> III. TANK OPERATOR INFORMATION , <br /> TANK OPERATOR NAME67a 428 1. p ) � / S_LA 428-2 <br /> MAILING ADDRESS /yl l 428-3 <br /> CITY 4284 STATE 428.5 1 ZIP CODE 428-6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME /l ala. PHONE 415. <br /> MAILING ADDRESS 416. <br /> CITY 417. STATE 418. 1 ZIP CODE 419. <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 EQUALIZATION UST;STORAGE FEE ACCOUNT NUMBER <br /> Ty(TK)HQ 44- k Q 1 d/j Ffftadl the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> q d 3cl 7 6 'VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 4%' <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify thatAe inform n provided herein is true accurate and in full compliance with legal requiremeng, <br /> . <br /> APPLICANT SIGNATURE DATE / / 424• 1 PHONE 425. <br /> APPLICANT NAME(print) � �A 426. APPLICANT TITLE f J� � r azo <br /> UPCF UST-A Rev.(12/2007) <br /> r <br />