Laserfiche WebLink
`✓ nc.00n r co <br /> STATE OF CALIFORNIA P i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A <br /> COMPLETE THIS FORM FOR EA HFACILRYISITE <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT e TEMPORARY SITE CLOSURE ' <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ory tat he-s < o a <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> giv E csf 6 X67- ,-0,-5- <br /> CITY NAME STATE ZIP CODE SITE PHONE S WITH AREA CODE <br /> ow/ CA <br /> -/ eoz <br /> TO INDICATE O CORPORATION INDIVIDUAL = PARTNERSHIP Q LONCV 0 COUNTY-AGENCY Q STATE-AGENCY 0 FEDERAL-AGENCYFEDERAL-AGENCYFEDERAL-AGENCYDISTRICTSTRICTSTRICTS <br /> TYPE OF BUSINESS Ee I GAS STATION 2 DISTRIBUTOR O RESERVATION✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.#(Iaph'maq <br /> 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST(C PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> or•T cc T� N 209— 517-1s,/6 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHnNF#WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME 7 CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADORES } ✓borbinAkaU 0 INDIVIDUAL Q LOGAL#GENCY STATE-AGENCY <br /> e/ %(`� O CORPORATION Q PARTNERSHIP COUNTY-AGENCY Q FEDERALAGENCY <br /> CITY NAME_ � STTtTE ZIP CODE PHONE 0 WITH AREA CODE <br /> S 52 0 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> G S �• <br /> MAILING OR STREET ADDRESS ✓ box 0WkaN D INDIVIDUAL Q LOCAL-AGENCY 0 STATE AGENCY <br /> 0 CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <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) HO 4 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Om binOkab D I SELF-INSURED 0 2 GUARANTEE E-1 3 INSURANCE 4 SURETY BOND <br /> D 5 LET ER OF CREDIT 97rS EXEMPTION O 99 OTHER <br /> VI. 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: I.D II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY At JURISDICTION# FACILITY It <br /> 1 / 106 MoKrrvi <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> Z3,g'C 3zS CW <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 IS FORM3A 5 <br />