COMPLIANCE INFO_2010-2012 - Laserfiche WebLink

Home Browse Search

completed UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-FACILITY INFORMATION (One form per facility) TYPE OF ACTION ❑ 1.NEW PERMIT �S.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE �• (Check One�Only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT L FACILITY INFORMATION TOTAL NUMBER OF USTs AT FACILITY FACILITY ID# 1 (Agency Use Only) - - BUSINESS NAME(s.mesFAcu.n•ymum ormA-Do;%e,�,y) 3. SA JoAdo W Coo-tit 4 j 4: DA PoAkfrAAJ v BUSINESS SITE ADDRESS 103. CITY 104. O ri: ZOL D A) OL- A) FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 4w' Is the facility located on Indian Reservation or 40• 3.FARM 4.PROCESSOR 6.OTHER T*ist lands? ❑Yes No II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407. PHONE 4K MAILING ADDRESS 409 P-0. �. r CITY , a1o. STATE 411• ZIP CODE a12. -fclk CA III. TANK OPERATOR INFORMATION TANK OPERATOR NAME42-1• 1 PHONE a28 2 MAILING ADDRESS 429.3 CITY 42s4 STATE 42.5 ZIP CODE 428-6 IV. TANK OWNER INFORMATION TANK OWNER NAME 414. PHONE 415. MAILIN;+G ADDRESS 416. V. lei n CITY 417. STATE 411L ZIP CODE 419. OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT 5.COUNTY AGENCY ❑ 6.STATE AGENCY am. ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT V. BOARD OF EQUALIZATIONUST STORAGE'FEE ACCOUNT NUMBER. TY(nQ AQ i47 10 1 A 4A Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. VL PERMIT HOLDERINFORMATION Issue permit and send legal notifications and mailings to: I.FACILITY OWNER ❑ 4.TANK OPERATOR 423 ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE4W (Required For Public Agencies Only) VII.APPLICANT SIGNATURE CE CATION: I cerft that the information providW herein is true,accunte.sad In fall com ce with Ifta requirements. f APP SIGNATUPE7 DATE 424• 1 PHONE lf' /Z) C cy 36 I i AeWCANT NAME(phot) 426. APPLICANT Tnu e JCS G cS AM-1.A4 UPCF UST A Rev.(I2/M7) w ;