Laserfiche WebLink
r <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ I.NEW PERMIT 'Q,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 INFORMA17ION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# <br /> (Agency Use Only) <br /> BUSINESS NAME(semwFAcaxryNAmEo,DBA-Doing B As) 3. <br /> kxk <br /> BUSINESS SITE ADDRESS t03. CITY 104• <br /> ' w ►�G- Aon-- <br /> FACILITY TYPE JH.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or 405• <br /> 3.FARM ❑ 4.PROCESSOR 6.OTHER Trust lands? ❑Yes o <br /> II. PROPERTY OWNER INFORMATION <br /> PRO OWNER NAME W PHONE • <br /> y'RAXw=t bW tApr- 3-77Y <br /> MAILING ADDRESS 409. <br /> CITY ` 410• STATE 411• ZIP CODE ate. <br /> III. TANK OPERATOR INFORMATION <br /> TANK O BATOR NAME 428-1. /PHONE ell 428-2 <br /> I ( ) <br /> MAILING ADDRESS 428-3 <br /> CITY 42&4 STATE 429-5 ZIP CODE 42" <br /> IV. TANK OWNER INFORMATION <br /> TANK O R NAME 414. PHONE 415. <br /> tvihax- 64 (Z96 ) 29L <br /> MAILING ADDRESS 416. <br /> CITY an. STATE als. ZIP CODE 419. <br /> M6A= m-- �57S3 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420• <br /> ❑ 7.FEDERAL AGENCY ❑ S.NON-GOVERNMENT <br /> V. BO OF EQUALIZATION UST STORAGETEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421' <br /> VI.PE ]KOLDEREWORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER J9 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 /> CERTIF I certW that the information provided herein is tree <br /> accurate,and in full compliance with legal requirements. <br /> APP= - DATE 424. PHONE 425 <br /> APPLI NAME(print) 426. APPLICANT ITLE 427 <br /> r <br /> s ; <br /> UPCF UST-A Rev.(12/2007) <br />