Laserfiche WebLink
<q bD 4 <q <br /> STATEOFCAUFORNIA < <`b� <br /> STATE WATER RESOURCES CONTROL BOARD s <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "m� y a <br /> COMPLETE THIS FORM FOR EAC FACILRY/SITE <br /> MARK ONLY Q 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT O s AMENDED PERMIT S TEMPORARY SITE CLOSURE 5r <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA RFACILITY NAME NAMEOFOPERATOR <br /> r u �ThL <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPr1DNAU <br /> 12 S- Cen4e- <br /> CITY M STATE <br /> 3� ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> .1 Box <br /> TO INDICATE CORPORATION O INDNIWAL =PARTNERSHP D LOCAL-AGENCY a COUNTYAGENCY O STATE-AGENCY E3 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR R V IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(#pl/Onal) <br /> Q 3 FARM Q A PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST.FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PWQN9 0 WITH AREA COOP <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION �� <br /> r hound Lc a�-W: E Iro <br /> M Alp.3 n,T E7App RESS bwkm 0 INDIVIDUAL � LOCAL-AGENCY 0 STATE-AGENCY <br /> bov && O3CZ RPORATION <br /> ED PARTNERSHIP Q COUMYAGENCY [::] FEDERAL-AGENCY <br /> CITY E �TE Z CODE$z� -O PHONE WITH AREA CODE <br /> (1a5III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS boabb9bw INDIVIDUAL O LOCAL-AGENCY (]STATE AGENCY <br /> 0 CORPORATION PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME 9TATE LP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HO Q Z S <br /> V. PETROLEUM AT FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> J ha bYMc#a D 1 SELF-INSUREDO GUARANTEE a 3 INSURANCE O A SURETY BOND <br /> D 5 LETTER OF CREW 5 EXEMPT ON Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 hecked. <br /> CHECK DNS BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L= IL 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(PA WTED a SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNFAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# c4yy JURISDICTION# FACILITY# <br /> C!] §Rcv N 1 z I I I /10[tgi qlo a) <br /> LOCATION CODE -OPTIONAL CENSUS TWTS -OPTJQNAL 33 SUPVIS%DISTRICT CODE -OPTIONAL OC/b 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(5.91) FOROW3A5 <br />