Laserfiche WebLink
ayes <br /> STATE OF CALIFORNIA "P�Q ��"� <br /> STATE WATER RESOURCES CONTROL BOARD s` ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A w�� v° <br /> os <br /> C�l��O1.Y•Y <br /> COMPLETE THIS FORM FOR EAC ACILTTYISITE <br /> MARK ONLY F--i 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT F-1 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE REn <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> /417Tv >Pf-rNGIIJ I. 1 L LA.+o l <br /> ADDRESS NEARESTCROSS STREET PARCEL 0(OPrONAL) <br /> FAN/AA f0 � 13`t- Ick-oq-G <br /> CITY NAME STATE ZIP CODE SITE PHONE#WI AREA CODE <br /> T 0f4 CA Kz4ql 44- Z <br /> TO INDICATE Q CORPORATION Ei-INDMDUAL =PARTNERSHIP L:j LOCAL-AGENCY COUNTYAGENCY 0 STATE AGENCY FEDERAL-AGENCY <br /> DGTWCTS <br /> TYPE OF BUSINESS O 3 GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN j#OF TAN S AT SITE E.P.A. I.D.#(OPAX ) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR d5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE M WITH Af EA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> ,f zufll:� Q ,,A -r-14 <br /> MAILING OR STREET ADDRESS ✓Ixx 0kwkm 11fr5NOIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> //0 CORPORATION I= PARTNERSHIP COUNTYAGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATF� ZIP CODE PHONE#WITH AREA CODE <br /> T �� 45 Zo <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Goods s,4- it s71�/L /coAQ`7 <br /> MAILING OR STREET ADDRESB `,...�.}� EP.bilft" INDIVIDUAL LOCAL-AGENCY STATE AGENCY <br /> 1I D� CORPORATION = PARTNERSHIP 0 COUNTYAGENCY 0 FEDEMLAGENCY <br /> CITY NAME STATE <br /> ZIP CODE PHONE#WITH AREA CODE <br /> `m CfT Z S zd <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 -� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II'Is ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.Z III.O <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 MONTWDAYYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUh-'A JURISDICTION It FACILITY# <br /> 0 D Z 8 /roar 60 <br /> LOCATION CODE -OPTIONALCENSUS3 .TRACT#Sa-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> o ( 2 <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 /> FOR0033A R2 <br /> FORM A(490) \ <br />