Laserfiche WebLink
�H 6 ! /Z W'-� <br /> 46 � � ' 1h <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> F 1 <br /> TYPE OF ACTION E] 1.NEW PERMIT Ll 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Check one item only) 3.RENEWAL PERMIT [3 6.TEMPORARY FACILITY CLOSURE L] 9.TRANSFER PERMIT <br /> TO I <br /> :ro <br /> 10 <br /> '5! M <br /> AL NUMBER OF LISTs AT FACILITY i <br /> -"1 619191 81 1 <br /> FACILITY ID# <br /> FlArenev U..ofilv) <br /> BUSINESS NAME(Seem&&FACILITY NAME or DBA-Win$Businas At) 3. <br /> kAMOS OIL-FRENCH CAMP <br /> BUSINESS SITE ADDRESS 103 CITY 104. <br /> 10842 SO.14ARLAN ROAD FRENCH CAMP,CA.95231 <br /> FACILITY TYPE 0 1.MOTOR VEHICLE FUELING [3 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM 4.PROCESSOR Q 6.OTHERTrust lands� El Yes No <br /> tit <br /> 11 1 A <br /> PROPERTY OWNER NAME 407. PHONE <br /> BENETO FAMILY TRUST (916)677-0817 <br /> MAILING ADDRESS 409. <br /> 4080 SEAPORT BLVD <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> WEST SACRAMENTO CA 95691 <br /> R"TRE <br /> N <br /> 14 'Mr ."N' -i M <br /> WIN .7" <br /> 1001M�,t <br /> 0 <br /> MEN <br /> 211 <br /> TANK OPERATOR NAME 429-1. PHONE 428.2 <br /> RAMOS OIL COMPANY (916) 371-2570 <br /> MAILING ADDRESS 422,3 <br /> P.O.BOX 401 <br /> CITY 428-4 STATE 4294 ZIP CODE 421-6 <br /> WEST SACRAMENTO CA - 95691 <br /> ME <br /> Pr- !iEa%! <br /> ff.M: <br /> MA <br /> w1. 1N <br /> NlUMla <br /> TANK OWNER NAME 414. PHONE 415. <br /> BENETO FAMILY TRUST (916) 677-0817 <br /> MAILINO.&MDRESS 41& <br /> 4080 SEAPORT BLVD <br /> CITY 41*7. STATE Ota. ZIP CODE 419, <br /> WEST SACRAMENTO ICA 95691 <br /> OWNER TYPE: El 4.LOCAL AGENCY/DISTRICT 0 5.COUNTY AGENCY [3 6.STATE AGENCY 420. <br /> ❑ 7.FEDIEPAL AGENCY S.NON-GOVERNMENT <br /> w ........ .--- <br /> ................... <br /> .W......Ol, .. <br /> TY TK H 44. 0 0 2 2 1 6 Call the State Board of Equalization,Fucl Tax Division,if thcrc arc questions. 421. <br /> FOR <br /> 011.g- <br /> ;_N. <br /> ft`sA <br /> E <br /> RIM <br /> RE <br /> 9:20. 10HU <br /> 423 <br /> Issue permit and send legal notifications and mailings to: 10 1.FACILITY OWNER Ej 4.TANK OPERATOR <br /> 0 3.TANK OWNER 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only)DAVE NELSON 406. <br /> *;�-";1®R <br /> wgg <br /> R 0 P.101"13. <br /> CERTIFICATION: I certif <br /> y that the information provide h is true,accurate,and in full com lienee with legal requirements. <br /> APPLICANT SIGNATUR!.j 424- 425� <br /> DATE PHONE <br /> -71-25-70 <br /> 10/27/2009 (916)3 <br /> APPLICANT NAME(print) 426, APPLICANT TITLE 427�1 I <br /> DAVE NELSON DIRECTOR OF SAFETY&TRAINING <br /> UPCF UST-A Re-i.(12/2007) <br /> LA 'd 9180 'ON AdSE :E 6002 <br />