Laserfiche WebLink
STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EACH FACILTTYiSITE <br />MARK ONLY Q NEW P — 3 RENEWAL PERMIT �5 CHA TION 0 7 PERIVXNENITLY CLOS SITE <br />ONE ITEM 2 INTERIM PERMIT 0 4 LADED PERMIT E 6 TEMPORARY SITE CLOSURE O <br />I. FACT Y/SITE INFORMATION & ADDRESS - (MUST BE,CyOMPLETED) <br />DBA OR AGILITY NAME' �V1 JZ <br />NAME OF OPERATOR <br />A K �i4 01) <br />FACILITY # <br />ADDR S fNEAREST <br />CROSS STREET <br />PARCEL# (OPTIONAL) <br />1 <br />�� �� <br />e,, <br />CITY ME <br />STATE ZIP <br />CO / <br />SITE PHONE WITH CODE <br />STATEZIP CODE <br />��� <br />TOINDICAT Q CO RATION INDIVIDUAL Q P TNERSHIP Q LOCAL -AGENCY Q COUNTY-AGENCY/v/ Q STATE -AGENCY Q FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS STATION 0 2 DISTRIBUTORQ <br />IF <br />✓ IF INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />4 PAOCESSOR 5 OTHER <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) NDARY) - optional <br />DA NAME (LAST, FIRST) PHONE # WITH AREA CODE DAY NAME (LAST, FIRSTI <br />_ -g - GNU '?�U - Z s <br />IGHTS: NAME (LAST, FIRS PHONE # WITH AREA CODE NIGHTS: NAME (LASFT, FIRST) <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAMECARE <br />APPLICANTS TITLE <br />OF ADDRESS INFORMATION <br />FACILITY # <br />MAILING OR STREET ADDRESS <br />✓ box Io indicate Q INDIVIDUAL <br />Q LOCAL -AGENCY Q STATE -AGENCY <br />/r V Z S <br />e,, <br />Q CORPORATION Q PARTNERSHIP <br />Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />T# <br />STATEZIP CODE <br />PHONE # WITH AREA ODE <br />-;.51--3 <br />1 <br />111. TANK OWNE11, FORMATION - (MUST BE COMPLETED) i AA" — �t% <br />NAME OF OWNER C 0 0 /j e—fo I p <br />APPLICANTS TITLE <br />CARE OF ADDRESS INFORMATION <br />FACILITY # <br />MAILING OR ST ET ADDRESS • <br />✓ box to indicateINDIVIDUAL <br />LOCAL -AGENCY STATE -AGENCY <br />/r V Z S <br />e,, <br />Q CORPORATION Q PARTNERSHIP <br />Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />M -rte — <br />T# <br />STATE ZIP CODE <br />s U <br />PHONE # WITH AREA CODE <br />"7'4'q -7, 36 - <br />IV. BOARD OF EQUAIL ZATK ST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />4 -_� <br />TY (TK) HQ 4 -1 --- - - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to indicate L, i SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE (] 4 SURETY BOND <br />n 5 LETTER OF CREDIT IQ 6 EXEMPTION EpJ OTHER <br />VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box Iorll' check -e?_.' <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. ❑ it. III. <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND COR T <br />APPLICANT'S NAME (PRINTED 8 SIGNATURE) <br />APPLICANTS TITLE <br />DATE MONTH/DAY/YEAR <br />FACILITY # <br />I I <br />LOCAL AGENCY USE ONLY LA✓/(.d <br />COUNTY #M1&O-r7 <br />` <br />JURISDICTION At <br />FACILITY # <br />I I <br />_oCATION CODS-1OPTIOpIAL <br />- OP,TTIIONAL <br />ICENSUS TRA <br />SUPVISOR - DISTRICT CODE - OPTIONAL <br />T# <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST It OR MORE PERMIT APPLICATION - FORM B. UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br />FORM A (12 91) FILE THIS FORM WITH TH� LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />FOR0033A-R6 <br />