Laserfiche WebLink
11 .. <br /> r ! STATE OF CALIFORNIA '`` •-' s .�, <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGF,01UND STORAGE TANK PERMIT APPLICATION - FORMA =-rx <br /> .Y' <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION D 7 PERMANENTLY C CRO S E <br /> ONE ITEM IC 2 INTERIM PERv' C 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION S A9='=-SS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> IG w - <br /> ADDRESS NEAREST CROSS STREET PAHCEta(OPTo"" <br /> CITY NAME STATE ZIP CODE SITE PHONE$Wi AREA=�-= <br /> CA <br /> •/ <br /> BOX — FARTNEFSHIP LOCAL AGENCY Cf COL'IRY-AGENCY C STAT EAGENCY _ `-- ��'='�`Y <br /> TOINgCATE ^PJ^ANON _ Q. C DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATIC\ _ _ =STRIBUTORO ✓ IFI-:AN $OF TANKS TAT SITE E.P.A. I.D. <br /> RESERVATION �V <br /> O 3 FARM — =OCESSOR 5 OTHER ORTRUSTLAIOS -t <br /> vV <br /> EMERGENCY CONTACT FE=.SIC LFRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(LAST.FIRST) '-:\Ex WITHAREA CO^E DAYS: NAME(LAST,FIRST) <br /> , Gati � �l0' g 2 7777 SPMA <br /> NIGHTS: NAME T,F'RST) _ \Ex WITHAREACODE MGHTS: NAME(LAST,FIRST) <br /> 211 A___ - <br /> IL PROPERTY OWNER INFORMATICN- .UST BE COMPLETED <br /> NAME CARE OF ADDRESS INFO;MAT10N <br /> MAIUNGORS?REETADDRESS D. 5 ✓ M.hlyd::¢e Gl INDIVIDUAL C—, LOCAL ACENCY __ : '6`E\CY <br /> D G/d•�1INf7 Wl, I ?�I CCRPCRATaN C PARTNERSHIP C CCUNIY.AGE'r_Y R NCY <br /> CITY NAVES//T'A'TE ZR CODE PNO,NNEE x WITH AREA.. <br /> i(JA <br /> III. TANK OWNER INFORMATION-;!'L'STBE COMPLETED) <br /> NAME OF CVtNE R CARE OF ADDRESS INFORMATION <br /> MApILING CR STREET ADO FESS ✓ Wx^indkale INDIVIDUAL C LOCAL AGENCY _ 3ENCY <br /> ORPOnAT10.h' Cj PART14ERSHIP = COUNTYACEIKY <br /> CITYI R-'AME Y ST TE21P CODE PHONE$WITH AREA <br /> / , em I <br /> L 2 ll�J <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)3239555 if questions arise. <br /> TY(TK) HQ 4 4 - �j ��j I— <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> pLp.Ac.v EO C 2 GUARANTEE C 3 INSURANCE <br /> ✓IN,b iMcale <br /> 6 EXEMPTION C 93 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 che:tied. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L[:] II. 5 III. <br /> THIS FORM HAS BEEN COMPLET JNDER PE LTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'SNAIAEIPRINTEDfi SIGN'ATURE) APPLICANT'STITLE DATE MONTH'CAY.YEAR <br /> C44-9 wU� 1`YJr g, <br /> LOCAL AGENCY USE ONLY <br /> COUNTY K JURISDICTION z FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL ICE NSUS TRACT$ -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM BI UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY.os <br /> FORM A(5'91) <br />