Laserfiche WebLink
UNIFIED PROGRAM CONSOLIDATED FORM D BD ?0-7327/7;7" <br /> UNDERGROUND STORAGE TANK 09_1-? '3 <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) �3 <br /> TYPE OF ACTION �'1.NEW PERMIT ❑-5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION e7,9 1 S �V <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. <br /> ei v� STvc iZ _ CR.O Cs�. o C t iP !LJ <br /> BUSINESS SITE ADDRESS' <br /> r /1 103. 'CITY t . <br /> s7YllcJ• /-re..c�. ar /wr• �-J1-acLr�,-- <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING El2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or a 5. <br /> ❑ 3.FARM ❑ 4.PROCESSOR &6.OTHER j12. 0.W• Trust lands? ❑Yes 9NO <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408, <br /> 6 <br /> MAILING ADDRESS 409. <br /> CITY 4t0. 1 STATE 411• ZIP CODE 412. <br /> �v a�r�:✓ e_q <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME <br /> /nj 428-1• PHONE 428-2 <br /> /`fq /'/ Ilrron ,r,ar.rxA \ //6 51:3-7 7 7v <br /> MAILING ADDRESS 428-3 <br /> CITY 428-4 ST�A�T�E, a2s-s ZIP <br /> �CODE 42M <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAMEII 414. PHONE 415. <br /> L:T ": . �,e c�� �0��I ) 'F3-7-9s'6-' <br /> MAILING ADDRESS - 416. <br /> CITY 417. 1 STATE 419. ZIP CODE 419. <br /> ST c'C',- - Cg C7.5- <br /> OWNER <br /> lsOWNER TYPE: LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 42L <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: �� 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE e- <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full com fiance with legal re uiremeks:-r <br /> APPLICANT SIG TURE DATE 424. PHONE 425. <br /> APPLICAN NAME(print) 426. APPLICANT TITLE 427 <br /> UPCF UST-A Rev.(12/2007) <br />