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 /> (Cheek one Item only) ❑ 3 RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACBdTY ID# _ t <br /> /D (Agenc)Use Only) - �' <br /> BUSINESS NAME(mine as Facility Name orD -DoingB/Ius__ine1ss As) 3 <br /> 111 c <br /> BUSINESS SITE ADDRESS103. CIT� IN, <br /> (��Y N�! a.I� �d• k-fwi <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the Facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR [yj 6.OTHER di)ec tr--3kW Trust lands? ❑ I.Yes tV2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME �_. 40Z PHONE 408. <br /> John CfilaS� <br /> MAILING ADDRESS <br /> P• o . &>c 0639") 4p9. <br /> CITY 9-C)^ K � 410, STATE 411 ZIPCODE 412. <br /> li Cid 'P 5 go K <br /> III. TANK OPERATOR INFORMATION <br /> TAMC OPERATOR NAME 428-1. PHONE 428-2, <br /> John GfnaSe- cac�1 > � '7S- (o�� <br /> MAILING ADDRESS 42e s <br /> P. d • �JOX �3�� <br /> CITY �-, 1 ©C 4284. STAT 428-5. ZIP CODE 428-0. <br /> :v �A � s a !K <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE415. <br /> (� /_' I 415, <br /> MAILING ADDRESS y^/ InM� �/ (y�� ��/f1 (ao 1 � `15-- 6C4O <br /> ` •D eox V 3 `1 416. <br /> CITY1 4n. STATE 418. ZIP CODE 419. <br /> I?7vl G4 9 5 ao 1� <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY El 6.STATE AGENCY 420 <br /> ❑ 7.FEDERAL AGENCY 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)l-IQ 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 railings to: I.FACILITY OWNER423. <br /> ❑ 4.'TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DMSION,SECTION,OR OFFICE(RequiredforPublic Agencies Only) 406, <br /> VII.APPLICANT SIGNATURE <br /> CE I ICATIO ertify that the informadou provided herein is true accurate and in full conaliance with le al re uirements. <br /> AP SI DA 424. <br /> PHONE 425. <br /> 2�1v .�'Iv63z� <br /> APPLI NAME � 426. AFLI TITLE 4n <br /> ✓lG� �}yI/ /�L <br /> UPCF UST-A Rev.(12/2007)-1/2 w ainidocs.org <br />