Laserfiche WebLink
e6W- f <br /> STATE OF CALIFORNIA <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , a <br /> COMPLETE THIS FORM FOR EACH FACILrrY1SrTE <br /> ._J� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION V7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DB F LITY NAME �^ NAMEOF OPERATOIJ <br /> App J NEARES SS/STTREEEETT PARCEL#(OPfIONAL) <br /> D -t rn <br /> CITY TATE ZIP Ct ��� � SITE PHO_yE STH AREA CODE <br /> CA N �T <br /> TOINDICATE O CORPORATION l� INDIVIDUAL EJ PARTNERSHIP LOCAL-AGENCY Q CWMY-AOENCV' (]STATE-AGENCY' OFEDERAL-AGENCY' <br /> N avner d UST Is a public agency,cor plste the fallowing:name of Supemieor of division section,w office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR = <br /> ✓ IF INDIAN s OF TANKS/1T SITE E.P.A. I.D.8(optional) <br /> RESERVATION / <br /> ❑ 3 FARM ❑ 4 PROCESSOR OR 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST.FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> NIGHTS: NAME(VST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(UST.FIRST) PHONE a WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓Owalntlksts l� INDIVIDUAL Q LDDALAGENCY STATE-AGENCY <br /> Q CORPORATION O PARTNERSHIP CWNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MALING OR STREET ADDRESS ✓ E0s0kdass 0IN0IVIDUAL Q LOCAL AGENCY STATE-AGENCY <br /> (]CORPORATION D PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE&WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ F4-[4--]- 'l 2 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPTED)—IDENTIFYTHE METHODS) USED <br /> ✓EmtbNdkW O 1 SELF-INSURED ARANTEE S INSURANCE 4 SURETY BOND <br /> D 5 LETTER OFCREDIT EV6 EXEMPTION 0 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 checked. <br /> CHECKONE 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 /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY ;� <br /> COUNTY a JURISDICTKM!f FACILITY t <br /> Eff ® jjjq,3 <br /> LOCATION CODE 09jrpr CENSlIT�NAI. 9UPVISOR-DISTRICT CODE TTJAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLE STH6IT, <br /> ACHANGE 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) FORGUtN P. <br />