Laserfiche WebLink
i <br /> RECEIVEQ , <br /> UNIFIED PROGRAM CONSOLIDATED FORM = 2015 <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMA �R90 <br /> TYPE OF ACTION [I1.NEW PERMIT ❑ 5 CHANGE OF INFORMATION El 7.PERMANENT FACILITY CLOSURE - 4n0' N' <br /> (Check one itemonly) ❑ 3.RENEWAL PERMIT. 6.TEMPORARY FACILITY CLOSURE [1 9.9.TRANSFER PERMIT L9 62-0 y <br /> 07 /75 <br /> I FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# <br /> �4tfC �(1iJf orAlL (Agenry Use Only) J� <br /> BUS SS NAMES. FACnITY NAMEurDBA—Doing Busi�M) 5. <br /> 1�G4N7- Z-oT i7,e o�.v��l/ i,ZE Sy�o G�4'' ar" LoJI f11 <br /> BUSINESS SITE ADDRESS 1m. CITY <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 40a' Is the facility located on Indi eservation or 4°_ s',, <br /> ❑ 3 FARM 4 PROCESSOR 6.OTHER Trust lands? ❑Yes No L4/(. <br /> ErEOIiERTY OWNER'INFORRIATION hh$ <br /> PROPERTY OWNER NAME 90. PHONE 404 <br /> T� �= Goin zo 3 A Aos <br /> MAILIN ADDRESS 409 <br /> 3© <br /> TY 410. STATE 411. ZIP CODE Ca. M i <br /> 1��N <br /> AL,-T'_ ...KAlj?ERA-T-OR� ORMATION,,, ' r <br /> TANKOPERATORNAME .. ... 428-1. PHONE 429.2 <br /> A�JK roan) E/IJ �CD SST ( ) <br /> MAILING ADDRESS 433-3 <br /> CITY 4A-4 1 STATE 4234 ZIP CODE 4284 <br /> TAN�PWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> i ? x 9 ' t/,0Jl (z® ) 33 mos <br /> MAILING ADDRESS ©� 416. <br /> CITY / 'J 412 1 STATus ZIP CODE7 Z / /O 419. <br /> OWNER TYPE: oK4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ .FEDERAL AGENCY ❑ S.NON-GOVERNMENT <br /> V?. WARD OF EQUALIZATION UST STORAGE FEE ACCOUN NUMBER <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tm Division,if there are questions. 421' <br /> VIz PERMYP HO ON <br /> Issue permit and send legal notifications and mailings w: ❑ FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 405. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII a1PT,reetilV�sT�NATUtE; <br /> CERTIFICATION: I certify that the information provided herein is true accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 'Im. PHONE 425. <br /> i-iG -es 20g <br /> APPLIC N _ - _ — 426 APPLICANT TI' 420 <br /> Gamic / 9. ROJ F /j1.�+✓�9G��( <br /> UPCF UST-A Rev.(12/2007) <br /> �r <br />