BILLING_2019 - Laserfiche WebLink

Home Browse Search

UNIFIED PROGRAM CONSOLIDATED FORM /I �� UNDERGROUND STORAGE TANK t b 10// I , OPERATING PERMIT APPLICATION-FACILITY INFORMATION (One form per facility) TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CI I;\NGE OF INFORMATION ❑ 7. IT MAN ENT FACILITY CLOSURE 400 (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE &'*9. I ILANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF LISTS AT FACILITY 404, FACILITY ID# (Agency Use Only) BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. 4 lr BUSINESS SITE ADDRESS 103, CITY 104. me 117.E FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or 405. ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes 9 No II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407. PHONE 408. MAILING ADDRESS 409. o CITY 410. STATE 411. ZIP CODE 412, 11 Z III. TANK OPERATOR INFORMATION TANK OPERATOR NAME 428-1. PHONE 428-2 MAILING ADDRESS 428-3 7o7- r_-- floe__ CITY 4284 STATE 428-5 ZIP CODE 428-6 e c A -3 IV. TANK OWNER INFORMATION TANK OWNER NAME 414. PHONE 415, 1 MA ( ) MAILING ADDRESS 416. CITY an. STATE a18. ZIP CODE Ore. CA- OWNER OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY ago. ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. VI. PERMIT HOLDER INFORMATION Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER 4.TANK OPERATOR 423 3.TANK OWNER ❑ 5.FACILITY OPERATOR 406, SUPERVISOR OF DIVISION,SECTION,OR OFI-ICE(Required For Public Agencies Only) VII.APPLICANT SIGNATURE CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. APPLICANT SIGNATURE DATE aza. PHONE 425. APPLICANT NAME( rin) 426 APPLICANT TITLE 7 UPCF UST-A Rev.(12/2007)