Laserfiche WebLink
f, <br /> UNnWD PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> LACTION <br /> PERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form per facility) <br /> l NEW PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> 3.RENEWAL PERMIT 116.TEMPORARYFACILTCY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTI AT FACILITY 406' FACI.ffYID# <br /> (AgaXy Use Owy) r 31Q <br /> BUSINESSNAME(smea Fnc1tm14nnrearnan-Doeseamm Oil <br /> BUSINESS SITE ADDRESS IOL CITY 104. <br /> FACILITY TYPE N 1.MOTOR VEHICLE FUELING ❑ Z FUEL DISTRIBUTION a01' Is the facility located m Indian Reservation or 405' <br /> 3.FARM 4.PROCESSOR 6.OTHER Tnut lmde7 ❑Yea ffNo <br /> M.PROPERTY OWNER INFORMATION <br /> PROPERTYOWNERNAME 4m. PHONE 408' <br /> MAn,ING ADDRESS <br /> CITY 4Ia STATE 411- Z@ z. <br /> CODE 41 <br /> III. TANK OPERATOR INFORMATION <br /> TAMC OPERATOR NAME 42%L PHONE 4ze-z <br /> MAILING ADDRESS 429-1 <br /> / <br /> CITY 4vn STATE Z�CODE 4r <br /> IV. TANK OWNER.INFORMATION <br /> TANK OWNER NAMEa14. PHONE - 41& <br /> 1 (soy ) 9�3-iis.3 <br /> MAILING ADDRESS 416. <br /> /Z/" w"" <br /> CITY 417. STATE 41a ZIP CODE 419. <br /> Gas �ti�� ��- <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY [16.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY E?FS.NDN-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST`STORAGE;FEE ACCOUNT NUMBER - <br /> TY CM)HQ 44- I 011412T () Call the State Board of Equali:atiM Fuel Tax Division,if there ate cl dotu. 421. <br /> VL PERMIT HOLDERINFORMATION <br /> Issue permit and send legal nodfiwtionv and medmgs W. (Kr I_FACILITY OWNER ❑ 4.TANK OPERATOR 4n <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Qaly) 4ox <br /> V&APPLICANT SIGNATURE <br /> CERTIFICATION: I c tha a Warmatiion provided herein is try acCtlrB and in fall cum ince with 1 UireMentL <br /> AP ANT SI A / DA 424. PHONE ass. <br /> �. / i G % <br /> —AAUCANT NAME 42& APPLICANTTITLE 47 <br /> DPCF USM-A Rev_(1=807) 10, <br />