Laserfiche WebLink
Cy JA f <br /> STATE OF CAUFORMA f c�S <br /> STATE WATER RESOURCES CONTROL BOARD i ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� ne <br /> � n � <br /> A CO PLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT F7 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM L] 2 INTERIM PERMIT F-1 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME meo7Ld NAME OFOP1CN ERA I <br /> ADDRESS / NEAREST GROSS STREET PARCEL#(OPTIONA4 <br /> GIiND NAGE S/TA�TCEA�+- ZI/� ITE P�ONFy _W�^R��E <br /> Yv BOX <br /> TOINDICATE O CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCALCTSENCY 0 COUNTY-AGENCY 0 STATE-AGENCY O FEDEPAL-AGENCY <br /> DISTRITYPE OF BUSINESS 3 GAS STATION 0 2 DISTRIBUTOR O ✓ IF INDIAN %OFT 5 AT SITE E.P.A. .D.%(optional) <br /> RESERVATION <br /> 3 FARM Q4 PROCESSOR 0 5 OTHER OR TRUST LANDS 04040 40 61 b-SL <br /> EMERGENCY CONTACT PERSON (PRIMARY) per, EMERGENCY CONTACT PERSON (SECONDARY)•optional C� <br /> DA!/��$ (LAST P OTHAREA CODE�17 JP� DAYS: (LAGT.FIRST) <br /> NIGHTS: NAME(LAST,FIRSTr) � PHONE%WITH AREA CODE NIGHTS: NAME(LAST,FIRST) O <br /> .Aero , 4:%t.1 A/ Gr - Z7Z' -� - goo z 72GOOF <br /> -63 <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CAREOF ADDRESS INFORMATION <br /> 'TSD /L/�Sa�J <br /> MAILINGOR STREET ADDRESS ✓ boa biMbate O INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> &J Q 3 ORPoRATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDEMLAGENCY <br /> CITU NAME STATE ZIP CODE HONE%WITH AREA CODE <br /> . ; G 7b2 60' 3/0� 01&7-Z <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> o CARE OF ADDRESS INFOR <br /> 1pieaoAt a <br /> MAILING OR STREE/�T�ADDRESS• y ✓ w kala 0 INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY <br /> �D. /yCJ)C ��t! CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL#GENCY <br /> CITY NAME STATE ZIP CODE ` " <br /> PHO % TH AREA C E <br /> C�— 907n�-6oao7- <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4T4] 0 0 0 5 0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ wbiMicateL;d<SELF INSURED 0 2 GUARANTEE D 3 INSURANCE O 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT 6 EXEMPTION O N 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: 1.O I.[:] III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTYOF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> -, �A82Co9 22 <br /> LOGAeNLOOE OPTIONAL ICENSUS TR � -OPTIONAL S�VISOR-DISTRICT CODE -OPTIONAL -�- <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION•FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM AIt2-BI) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0039A16 <br />