Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM � ) <br /> UNDERGROUND STORAGE TANK 1 <br /> OPERATING PERMIT APPLICATION-FACILn Y INFORMATION <br /> (One form per fac 7ity) <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 /> L FACILITY INFQRNiATION <br /> TOTAL NUMBER OF USTs AT FACILITY 41, FACILITY ID# T- <br /> (Agency <br /> Use Only) I 71 1 [ '1- 1 1 1 1 <br /> BUSINESS NAME(same as FA n=NAME o DBA-Deing Busine�Aa) 3 <br /> ,'V'1 0- .4 -Y) A---P, (E7N i 6-71fZ (S S <br /> BUSINESS SITE ADDRESS 103. <br /> { 6 © S 5 • C i--.c o le A--0o S+ <br /> FACILITY TYPE MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> 3.FARM 0 4.P ROCESSQR ❑ 6.OTHER Trust lands? ❑Yes <br /> II..PROPERTY:OWNER_INFORMA N <br /> PROPERTY OWNER NAME 407. <br /> L-3 /r L-A--j--% A-(\) c,7L PHONE ao8. <br /> MAILING ADDRESS <br /> 3 5 S`v'�-` Gid f LJ tv ti/r`F A� �1 ao9. <br /> CITY 410• STA411• ZIP CODE 412. <br /> two tv i _ R t-C <br /> III. TANKQPERAT©R INFORMATI PT: <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> MAILING ADDRESS 428-3 <br /> 3 C <br /> CITY 428-4 STATE ZIP CODE 428 <br /> l c <br /> IV. TANK OWNER INFURMATION <br /> TANK OWNER NAMEPHONE 415. <br /> /y _ 414. <br /> MAILING ADDRESS 416. <br /> 3 �- C-0 DV A AJ J-�A/ � <br /> CITY 417, 1 STATE 418. ZIP CODE 419. <br /> 4 3 <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 EQIIALIK*TINUST SQItAGIF-FEEAOUNT.NUhIBER' <br /> . , . <br /> TY(TK)HQ 44- Call the State Board of Equalizatio Fuel Tax Division,if there are questions. 421. <br /> W.PERI HOLDER.INF -TIO <br /> Issue permit and send legal notifications and mailings to: ❑ 11.FACILITY OWNER [34.TANK OPERATOR 423 <br /> 6,Y1ANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DMSION,SECTION,OR OFFICE(Required For Public 406. <br /> (Rego Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I t the information provided herein is tru accurate,and in fall 4 empliance with legal requirements <br /> APPLICANT SIGNATU DATE / 424, PHONE <br /> Lt <br /> APPLICANT NAME(pnnt 426• APPLICANT TITLE <br /> UPCF UST-A Rev.(12/2007) <br />