Laserfiche WebLink
f <br /> cs u• � <br /> STATE OF CALIFORNIA ° i <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD W., n <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A „� a <br /> 1/' COMPLETE THIS FORM FOR EACH FACILITYISITE °'��•���'- <br /> MARK ONLY 0 1 NEW PERMIT O 3 RENEWAL PERMIT )j<'5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 6 ADDRESS-(MUST BE COMPLETED) <br /> OBAO FACILITY NAME NAME OF OPERATOR <br /> A R NEAREST CROSSTREET PARCEL E <br /> CITY NAM STATE SITE PH NES WITH AREA COOE <br /> CA a— ao9 <br /> ✓ BOX CORPORATION INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY �COUNTY-AGENCY' O STATE.AGENCY' O FEDERAL-AGENCY' <br /> TOINDICATE DISTRICTS' <br /> N owner d UST Is a public agency.ownplele the I :name of Supervisor of division,section,or o lice which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR R V IF INDION IANINOFTANKSATSITE E.P.A. I.D.S WAmr al) <br /> 0 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: ME(LAST,FIRS P NE S TH AREA CODE DAYS: NAME(LAST.FIRST) PHONE S WITH AREA CODE <br /> o - b <br /> NIGHTS: NAME( T,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> N Qi IOCARE O ADDRESS INFORMA N of <br /> MAILING OR STREET ADD ESS ✓ b Q INDIVIDUAL E3 LOCAL-AGENCY STATE-AGENCY <br /> e CORPORATION O PARTNERSHIP 0 COUNrY-AGENCY 0 FEDERAL-AGENCY <br /> CI NAME ASTATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) C <br /> NAME OF OWNER ^ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bsa to iMicats E:I INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> O CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CRY NAME STATE ZIP CODE PHONE S WITH 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 METHODS) USED <br /> ✓but mktle O 1 SELF-INSURED 0 2 GUARANTEE O INSURANCE 0 4 SURETY BOND <br /> O 5 LETTEROFCREDIT O B EXEMPTION w 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 chocked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I,= II. III, <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAYNYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION x Lrry r <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS -OP NAL SUPVISOR-DI OP <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3'93) a <br /> Fp Op <br /> GG ;s 1 rto� 7�yr 11 t t � 5 <br />