Laserfiche WebLink
" t9 <br /> STATE OF CALIFORNIA �. <br /> STATE WATER RESOURCES CONTROL BOARD sy m <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> /6.� /. ro . <br /> COMPLETE THIS FORM FOR EACH FACILRYISRE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ D RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA Op FACILITY NAM NAME OF OPERATOR <br /> K0f WOO 11�'Y <br /> ADDRESS <br /> 3 q �C v r4�r /P �. <br /> NEAREST CROSS STREET PARCEL#(OWIOID <br /> d 0 � . <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> CA <br /> TO INDICATE fD CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 OOUNIY-AGENCY STATE-AGENCY <br /> DISTRICTS O FFDEML-AGENCY <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTORO RES✓ERVA <br /> IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a(oplAw* <br /> TION <br /> ❑ 7 FARM Q 4 PflOCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE f WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AflEA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAMEKJ p CARE OF ADDRESS INFORMATION <br /> � a Pn��ue� <br /> MAILI ORSTREE/T/j�.CIDREVSS ✓ bbd Q IND (DUAL I� LOCA4AOENCV STATE#GENCY <br /> 1 /J CORPORATION 0 PARTNERSHIP �COUNTY#GENCY FEDEMLAGENCY <br /> CITY NAME ST ZIP CO E PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION- (MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS —77 bu;b iMhu 0 INDIVIDUAL 0 LOCALAGENCY 0 STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE R WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739.2582 if questions arise. <br /> TY(TK) HQ F4]-4]-L LI�L J <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II' checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ N. 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&SIGNATURE) APPLICANTS TITLE DATE MONTHIOAWYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY JURISDICTK)Na FACILITY �PoA0r3y <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR--DISTRICT CODE -cFnOAAL <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) FOA0=AA2 �, <br />