Laserfiche WebLink
LL � � <br /> STATE OF CALIFORNIA ^.� <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A mg <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ^.,,,a,,,,•' <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 1p;4 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT E:71 0 AMENDED PERMIT <br /> Q 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACT TTY NAME NAME OF OPERATOR <br /> ADDRESS _ <br /> SG NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME <br /> STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> CA <br /> TO INDICATE O CORPORATION D INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY ED COUNtY-AGENCY' 0 STATE-AGENCY' O FEDERALAGENCY' <br /> N oener al UST Is aublc en DISTRICTS'p +W ty,oorrplele the tollowinB:name of Supervior of dNkbn,section.W of lot which operates the UST <br /> TYPE OF BUSINE STATN3N F-1 2 DISTRIBUTOR ,/ IF INDIAN #OF TANKS SITE E.P.A. I.D.s(epNAatd) <br /> 3 FARM - O 3 PROCESSOR = 5 OTHER OOR TRUSTVATION LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME MST,FIRST) PHONE s WITH AREA CODE <br /> :] <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAIUNGORSTREE ADDRESS ✓box blMkNe D INDIVIDUAL 0 LOCAL-AGENCY D STATE-AGENCY <br /> �j•� ��2 D CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY D FEDERAL#GENCY <br /> CITY ME � STATE 6 ZIP CODE�O� HryIE�I ITA COD <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OVYNER CARE OF ADDRESS INFORMATION <br /> MAILING/OR STREETADDREESS/� ✓ DoxbintlkNe D INDIVIDUAL 0 LOCAL-AGENCY O STATE AGENCY <br /> Aov 1Z 0 COIIPOMTION D PARTNERSHIP D COUNTY#GENCY 0 FEDERAL-AGENCY <br /> CITY AVE STATE A I ZIP CODE PHO #kITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Im bYtlbate O t SELF-INSURED O 2 GUARANTEE D 3 INSURANCE D A SURETY BOND <br /> D 5 LETTER OF CREDIT D I EXEMPTION D 95 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: LD II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED a SIGNED) OWNER'S TITLE DATE MONTHOAYYVEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a FACILITY It <br /> 2 / Io /1 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPT70NAL <br /> p 71 i- -527-- <br /> This <br /> ZZTHIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(area) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKINB <br />