Laserfiche WebLink
STATE OF CALIFORNIA ^[[,,« <br /> A [5 <br /> STATE WATER RESOURCES CONTROL BOARD '�, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A `� a s <br /> Y^ C�l/[O�N.[ <br /> 5/ COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 1y15 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE 7, <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OS/�pR FACILIjV NA)IE�� �� NAMMEEOyFFOOPERATOR <br /> ADDDDR'EYS!/Sd�ND7 / SS STREET PARCEL#(OFnONAL) <br /> v ty !AV/ <br /> CITY STACA ZIP CODEs� Py#WITHpR CO / <br /> ✓ BOX <br /> TO INDICATE ORPORATION l�INDIVIDUAL l�PARTNERSHIP 11 LOCAL-AGENCY D COUNTY-AGENCY STATE AGENCY FEDERAL-AGENCY <br /> DGTRICTS <br /> TYPE OF BUSINESS i GUSTATION = 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(oplArwl) <br /> TION <br /> 3 FARM 4 PROCESSOR 5 OTHER TRUST ANDS <br /> ❑ ❑ OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAME(LAST,FIq P NE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> xA <br /> NIGHTS: NAME( T,FIRST) N #WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM �� - _ _ CARE OF ADDRESS INFORMATION <br /> MAILINGORSTREET ADDRESS Coc blMkau D INDIVIDUAL O LOCAL-AGENCY (]STATE-AGENCY <br /> GGA PORATION [::] PARTNERSHIP Q COUNTYAGENCY 0 FEDERAL-AGENCY <br /> CITU NAME/ ' ATE ZIPCODE E#WITH AREA E <br /> !x/13• �' 33 -E <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAAW OF OWNER CARE OF ADDRESS INFORMATK)N <br /> G <br /> MAILING OR STREET ADDRESS ✓ EmbWM W � INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> �/ l�CORPORATION l� PARTNERSHIP O COUNT-AGENCY 0 FEDERAL-AGENCY <br /> NAME STATE- ZIP COQ /Q HONE#IYITH9RFAC9&2., <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-25882 if questions arise.J ''J�/J <br /> TY(TK) HO 4 4 -L]=[:= <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 11. III,❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNT'# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUI�ACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OP77ONAL G- <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. <br /> FORM A(9-90) FORMA-R2 <br /> 110 <br />