Laserfiche WebLink
ggUUA <br /> STATE OF CALIFORNIA p' •""- <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> C�l"Oe M,n <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O I NEW PERMIT O 3 RENEWAL PERMITCHANGE OF INFORMATON IX 7 PERMANENTLY CLOSE <br /> ONE ITEM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT R-116 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DQJOR FACT VNAME fQ --IM FA�OM�E�OF� ERATOR jtt pit�/I <br /> QIxV LA tx3ax W1161 U'Yl x—WYN (� 1/� E/Y x <br /> ADDRESS AI��W - � Wet I AR TCS STZt, PARCEL#(OPTIONAL) <br /> CI NAME �� <br /> STATE 21P�PODE SITE PHONE# <br /> WITH AREA CODE <br /> �� <br /> �ti <br /> ✓ Box �y <br /> TO INDICATE ED CORPORATION I]INDIVIDUAL f]PARTNERSHIP xg LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL#GENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O T GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#IgXomap _ <br /> O O RESERVATION WOO <br /> �O� �� .'J <br /> 3 FARM 2 PROCESSOR 5 OTHER Dq TRUST LANDS W 4 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY <br /> NA (LAST,FIRST) r PHONE WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> AI.t, �- 0 Vt a.\ IA s ')Zqo <br /> NIGHTS: NAME(LAST, RST) PHONE Al WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE v WITH AREA COnP <br /> II. PROPERTY OWNER FORMATION- MUST BE COMPLETED <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR Sj]�ET ADDRESS \��/-/�••V•(7n'l/.T ✓ bxblnd� INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCYl © . ISO Z/Z =CORPORATION Q PARTNERSHIP 0 COUNTY#GENCY 0 FEDEML#GENCY <br /> CI AVE �� STATE. 21P CODE HONE WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) l/J4`_ L��[ 1 Ccjca` Z7 <br /> N M OFO ER / A ��f CARE OF ADDRESS INFORMATION <br /> MAILING�OR ST LlllTw`AD_DJRVE/SM9'•"21` -7 ✓ box b Indicate 0 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> Rc>a 4 7 {✓ O CORPORATION = PARTNERSHIP E::]COUNTY#GENCY I] FEDERAL-AGENCY <br /> CI E l k STATE 2C,v � HONE IT ARERCO77�,q) <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER R--Call(91'/6l')tJ3^23-9555 if question arise. CC/(a Jr V <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bmdcate 0 I SELF-INSURED 2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND <br /> 715 LETTER OF CREDIT 0 6 EXEMPTION M OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOx INDICATING WHICH ABOVE ADDX SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. 111.O <br /> THIS FORM HAS BEEN COMPLET UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APfL�IaC�ANTTS VME�(P/RIN�T�ED•&SIGNA AP UCANT TIT DATE MONTW4DAYNEAR <br /> jf+I&/�L�-l.ld.l 'Q•K ( Q Ll1'V�1n 1- <br /> LOCAL AGENCY USE ONL <br /> COUNTY# JURISDICTION# l0 FACIL 9 <br /> (� 1pj <br /> �, ll (&4 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 7 <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION NLY. <br /> FORM A(5.91) FORDDDA 5 <br /> .11111W <br />