Laserfiche WebLink
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) Qr3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 41 FACILITY ID# _ t` <br /> (Agency Use Only) <br /> BUSINESS NAME(sam as FAcnHy NAME or DBA-Doing Bum=As) 3• <br /> T L'�a G® k^`Ct i) V rt S 4® "Z <br /> BUSINESS SITE ADDRESS 103• CITY 104. <br /> FACILITY TYPE W1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 405' <br /> 3.FARM Q 4.PROCESSOR 0 6.OTHER Trust lands? ❑Yes ON'o <br /> U. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4W• PHONE 408• <br /> D <br /> MAILING ADDRESS 409.ID G � 2 ' <br /> CITY 410. STATE all. ZIP CODE 411 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 429-2 <br /> MAILING ADDRESS 420- <br /> CITY 42&4 STATE 428-5 ZIP CODE 428.6 <br /> I�vd ; 52x2 <br /> IV. _TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> MAILING ADDRESS 4167 <br /> CTiY �49 1 ate. STATED ars. ZIP CODE L4 L 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420• <br /> ❑ 7.FEDERAL AGENCY eS.NON-GOVERNMENT <br /> V. OF EQQUALIZATION UST StTO GE.FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 0 2- CA Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PE HOLDER-INFORKATION <br /> Issue permit and serol legal notifications and mailings to: 13%FACILITY OWNER [14.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DMSION,SECTION,OR OFFICE(Required For Public Agencies Only) 406' <br /> VII APPLICANT SIGNATURE <br /> CERTIFICATION: I ce that the information pEjvfded herein is traaccura and in full com Bance with r uirements.P <br /> APPLIC NA DATEE 429. PHONE <br /> 425. <br /> b�1 1°�` <br /> APPLICANT NAME(print) 426. APPLI TITLE v 0- <br /> '-TOM <br /> n'-TOM SAO nes. 0wtip/�- <br /> UPCF UST-A Rev.(1 <br />