Laserfiche WebLink
Le J <br /> ... STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A : <br /> �.I COMPLETE THIS FORM FOR EACH FACILTrYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED S1TE <br /> ONE REM E] 2 INTERIM PERMIT e AMENDED PERMIT 6 TEMPORARY SITE CLOSURE Q <br /> 1. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DGAOR FACIIITY NAME NAME OF OPERATOR <br /> vNw � ua2 <br /> ADDRESS NEAREST CROSS STREET PARCEL✓r(OPrIONAU <br /> 2i6eff:,. rce-7�4 oZ-7- oho- <br /> CITY NAME ST ZIO 32�� ITE PHONE#WITH ARTA CODE <br /> CA <br /> G•oD� ! 101) 3 - ! <br /> TOIN Box O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY 0 COUNTY.AGENCY' STATE-AGENCY' 0 FEDERAL-A(ENCY' <br /> DISTRICTS' <br /> •N owner of UST Is a public agency,complete the following:name of Supervisor ol divi l n,seclbn.W office whish op Wales the UST <br /> TYPE OF BUSINESS ' <br /> GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN IN OF TANKS AT SITE E.P.A. I.D.#(tpNmall <br /> RESERVATION <br /> 3 FARM O 6 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME( T,FIRS PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> 'r 368- <br /> NIGHTS: NAME(UST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME ` r CARE OF ADDRESS INFORMATON <br /> A GTN•/ / O <br /> MAILING OR STREET ADORES ✓box loMtlbas 0 INDIVIDUAL = LOCAL-AGENCY O STATE-AGENCY <br /> Fo 'E 7/w /Z-- Q CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY O FFDERALAGENCY <br /> CITY NAME STATE ZIP CODEHONE#WITH AREA CODE <br /> G o pi � -761z4/a ar-t 333-/0 <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMED WNES CARE OF ADDRESS INFORMATION <br /> /Q NI <br /> MAILING OR STREET ADD/PpESSL� ✓ bi�caN 0 INDIVIDUAL 0 LOCAL AGENCY 0 STATE-AGENCY <br /> �/ CORPORATION D PARTNERSHIP (] COUNTY-AGENCY 0 FEOERALAGENCY <br /> CITY NAME STATE ZIP CODE HONE WITH AREA CODE <br /> lire-' <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322.9669 it questions arise. <br /> TY(TK) HQ F4-F4--]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box OYiSW9 0 1 SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE O X SURETY BOND <br /> 0 5 LETTEROFCREDIT 6 EXEMPTION (] 90 OTHER <br /> VI, LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.O III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED A SIGNED) OWNERS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACLIT V 1T <br /> ih] 4o 13[315-1y <br /> LOCATION CORE -OPTIONAL CENSUS TRACT#-OPTIONAL SUPVLIM-DISTRICT CODE -OPTFONAI. <br /> 07 1 23 . BCU <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. A <br /> OWNER MUST FILE THE FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS lA <br /> FORM A(393) ` <br />