Laserfiche WebLink
STATE OFCALIFORNIA °o^ <br /> STATE WATER RESOURCES CONTROL BOARD ` B <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> i i... o <br /> "�� <br /> �i <br /> COMPLETE THIS FORM FOR E FACILITYfSITE �""°""'� <br /> MARK ONLY E] r NEW PERMIT E] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT d AMENDED PERMIT O e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> NAME OF OPEflATOR <br /> A DRESS0 � <br /> NEARESTCROSS STREET PARCELN(OPnONAL) <br /> CITY NAME f/VJL. <br /> SSTATE ZIP rO E SITE PHONE*WITH AREA CODE <br /> Box CA �I <br /> TO INDICATE O CORPORATION ED INDIVIDUAL 0 PARTNERSHIP O LGCAL-AGENCY <br /> DISTRICTS COUNTY-AGENCY O STATE-AGENCY FEDERAL-AGENCY <br /> TYPE OF BUSINESS 0 t GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN NOF TANKS SITE E.P.A. L D.N(aplAaiAq <br /> O 3 FARM Q 6 PROCESSOR 5 OTHER O TRUST ATION <br /> NDS <br /> O OR TRUST LANDS G� <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY§'. NAME ILAST.FIRST) PHONE WITCH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 43—44cs� <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONEN WITH AgEA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR TREETADDRESS`, �/�/ ✓Nor birdka ED INDIVIDUAL L11I�LOCAL40ENCY STATEAGENCY <br /> 6!6zZ �L✓M D�.IT �y�[X� ED CORPORATION = PARTNERSHIP E�j COUNrYAGENCY 0 FEDERIL-AGENCY <br /> CITY NAME STATEA ZIP CODE ONE N WITH AR A CODE <br /> III. TANK OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME OWNER CARE OF ADDRESS INFORMATION <br /> D4 `7A- <br /> MAILINGORSTREETADDRESS ,^ ✓box bindbNN 0INDIVIDUAL = LOCAL AGENCY Q STATE-AGENCY <br /> 969 Z �3'�4— CORPORATION 0 PARTNERSHIP =COUNTY-AGENCY FEDERALAGEWY <br /> CITY NAME STATE ZIP PHONE N WITH AREA CODE <br /> o G/3, 9 Zo <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2682 if questions arise. <br /> TY(TK) HQ [4 74 -� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.ED IL O 111.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 MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION IP FACILITY N <br /> 13A I I 110VE APAI-r- 8'l <br /> LOCATION CQDE -OPTIONAL CENSUS TRACT ND OPTIONAL SUPVISOR- ISTRK:TOODE -OPTIONAL r,--r7 -r <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE O/? ATION ONLY.=3 <br /> A-RR <br /> FORM A(9-90) l <br /> `w <br /> / <br />