Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARDy. <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A <br /> 4XN� <br /> COMPLETE THIS FORM FOR EAcpA6LrrvSITE <br /> MARK ONLY O I NEW PERMIT O 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 a TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBAOR FACILITY NAME / NAMEOFOPERATOR <br /> ADDRESS I'A.P� NEAREST CROSS STREET PARCEL%(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE%WITH AREA CODE <br /> r CA s .20 - ycs-osa�o <br /> I/ BOX <br /> TO INDICATE CORPO TION INDIVIDUAL = PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY 0 STATE-AGENCY O FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESSEL?rl GAS STATION 0 2 DISTRIBUTOR / IF INDIAN %OF TANKS AT SITE E.P.A. I.D.a(opt/mal) <br /> RESERVATION <br /> O 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE%WITH <br /> J[// 10 AREA CODE q FIRST) <br /> _ S <br /> OSa/ s6tt.&--I— PHn <br /> NIGHTS: <br /> --I - <br /> NIGHTS: NAME(LAST.FIRST) PHONE%WITH AREA CODE NIGHTS: NAME(LAST,FIRST( <br /> � 4 0mayPHONE v WITH AREA COr <br /> — <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME I CARE OF ADDRESS INFORMATION <br /> vele ' Atc , <br /> MAILING OR STREET ADDRESS ✓ boa bintlbale INDIVIDUAL Q LOCAL-AGENCY 0 STATE AGENCY <br /> D CORPORATION O PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY <br /> STAT <br /> CITY NAME E ZIP CODE PHONE%WITH AREA CODE <br /> ckA> , CA <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> SZge <br /> MAILING OR STREET ADDRESS ✓ bmbinEbale E-3 INDIVIDUAL LOCAL-AGENCY O STATE AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERALAGENCY <br /> CITY NAME STATE ZIP 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) HQ F4141- 0 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boa biMbab O I SELF INSURED 0 2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND <br /> D 5 LETTER OFCREDIT D 6 EXEMPTION 99 OTHER <br /> 71 <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I x checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. 11.O 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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# GOTEL/� FACILITY# <br /> ® 1 1 1 ivy <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 3 <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) FORBa33A 5 <br /> 7 � <br /> 4wI ♦ 4 v��/4 <br />