Laserfiche WebLink
STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD w r o <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ,,, os <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE C+ipOrtN'- <br />MARK ONLY t NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br />ONE ITEM 2 INTERIM PERMIT = 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLFTFDI <br />DBA OR FACILITY NAME <br />NAME OF OPERATOR <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />Co MA,2T SA=v <br />ADDRESS <br />714 <br />NEAREST CROSS STREET <br />PARCEL # (OPTIONAL) <br />✓ box to indicate INDIVIDUAL <br />(] LOCAL -AGENCY STATE -AGENCY <br />T k <br />CITY NAME <br />�4 �c <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />ZIP CODE <br />CA <br />qS374 <br />(2 0) F33 - <br />BOX. <br />TOINDICATE CORPORATION INDIVIDUAL PARTNERSHIP LOCAL -AGENCY COUNTY -AGENCY' 0 STATE -AGENCY' = FEDERAL -AGENCY' <br />DISTRICTS' <br />It owner of UST Is a public agency, complete the following: name of Supervisor o1 division, section, or office which operates the UST <br />TYPE OF BUSINESS = t GAS STATION = 2 DISTRIBUTOR <br />✓ IF INDIAN <br />1# OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />0 3 FARM = 4 PROCESSOR = 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) FMFa(;FNCv mu-rnrT oGoenu 1eE:r1nMnAOV1 ---r <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION - (Ml1ST RF MMPI FTFm <br />NAME h j"� /' <br />t <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to indicate INDIVIDUAL <br />(] LOCAL -AGENCY STATE -AGENCY <br />T k <br />0 CORPORATION Q PARTNERSHIP <br />Q COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />= FEDERAL -AGENCY <br />PHONE # WITH AREA CODE <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />C1�y) 833 - /S - <br />III. TANK OWNER INFORMATION - (MI IRT RF MMPI FTFrn <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS llpopfe 1 <br />INDIVIDUAL <br />� LOCAL -AGENCY <br />STATE -AGENCY <br />E-1 CORPORATION PARTNERSHIP <br />= COUNTY -AGENCY <br />= FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />Iv. bUAhU Ul- tUUALICA I IUN U51 5I UHAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. <br />TY (TK) HQ L4[4-1- - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED <br />✓ box to indicate f� t SELF INSURED [-12 GUARANTEE Cl 3 INSURANCE <br />D 4 SURETY BOND <br />5 LETTER OF CREDIT ED 6 EXEMPTION CI 99 OTHER - - kib —I In k) T.. <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 />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. F7 it. L—] III. E] <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />)WNER'S NAME (PRINTED 8 SIGNED) ;t N OWNER'S TITLE DATE MONTWDAYNEAR <br />1)19E,qA70A <br />LUUAL AuENL:Y U5t UNLY <br />COUNTY # JURISDICTION # FACILITY # <br />m <br />LOCATION CODE - OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL <br />t nw rvnm mw i Or Al.wmrAnitU by All LtA5I (1) UH MUHL PLHMIT APPLICATION' 1-UHM d, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />FORM A (3/93) 1 FOR0033A-i7 <br />