Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMA l J <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 99.TRANSFER PERMIT <br /> I. FACILITYINFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# IFI <br /> I' <br /> �vvl (Agency Use Only) _A _ O I <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. <br /> U USN CSU SfV ( <br /> BUSINESS SITE ADDRESS 103• CITY 104. <br /> `ZCk b TH1?,L)P P-U t <br /> FACILITY TYPE P4-1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM El 4.PROCESSOR ❑ 6.OTHER Trust lands? []Yes nNo <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 40T, PHONE 408. <br /> wfA T CAM�I �- <br /> MAILING ADDRESS 409. <br /> 0O 2 Q•Ot <br /> CITY 410. STATE 411• ZIP CODE 412• <br /> s NV � ►�r � <br /> III. TANK OPERATOR INFORMATION <br /> TANK OP BATOR NAME 428-1• 1 PHONE 428.2 <br /> MAILING ADDRESS 428.3 <br /> CITY 4284 STATE 828-s ZIP CODE r 428.6 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> I 416. <br /> MAILING ADDRESS , <br /> CITY a1z STATE 418. 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: BOARI3 OF EQUALIZATION USY 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.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) 406' <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate and In full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. 1 PHONE_ e^-•.4 <br /> 6V 10- <br /> APPLI T NAME(print) 426• APPLIC T TITL 4n4 <br /> T Fit <br /> UPCF UST-A Rev.(12/2007) n <br />