Laserfiche WebLink
a <br /> STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM ACOMPLETE THIS FORM FOR EACH FACILTTYISTTE <br /> MARK ONLY F-1 I NEW PERMIT O 3 RENEWAL PERMIT X 6 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM O 2 INTERIM PERMIT [k4 AMENDED PERMIT a g TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORF ILITYNAME NAME OF OPERATC12 /� / <br /> ua' <br /> ADDRESS 3� �''K' NEAREST CROSS STREET 1LJ C'vP_ARCELq� Ji(_OPr•L <br /> CITU NAME ►v" ST CA ZIP � ^� SBox 7I AREq_ODE���) 1 <br /> TOINp TE CORPORATION O INDIVIDUAL (]PARTNERSHIP O LOCAL-AGENCY �COUNTYAGENCV• D STATE-AGENCY• O FEDERALNENCY' I <br /> 'ff..dUSTka -ie DISTRICTS <br /> p agency,mnplde the lo5owln3:nertle d Supervbor d ONbbn.sedan,or office which operates the UST <br /> TYPE OF BUS[ 1 GAS STATION 0 2 DISTRIBUTOR O -/ IF INDIAN I OF TANKS AT SITE E.P.A. I.D.I(pplblld// I <br /> RESERVATION ._^ZJ <br /> 3 FARM Q 4 PROCESSOR Q e OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS. NAME(LA!�p� . � I�F CppE� DAY$RNA• 1 , P ONE i H AREA CAD��� <br /> N TS: NAME LAST,FI .JMdRR3}i� 4•.1.l3/VJA�1 WITH ARREE-CODES NV�TS:/ E( T,F /K'/•11• PHOL'N16WLTITH AREA CODE <br /> J7-)Va"eYL+i ' ,L ast <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAMEs AD DRESS INFORMAT <br /> G. & ION <br /> M'AIL��CaJORSTREETAPDRESS ✓ Oo6 bYltlka4 0 INDIVIDUAL O LOCAL-AGENCY 0 STATE-MENCY <br /> 1 'C) IJ O� ORPORATKIN [:] PARTNERSHIP Q COUNTY-AGENCY =FEDEMLAMNCY <br /> CITY NAME STA ZIP CODE PHONE I WITH.AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OWN CARE OF RESS INFORMATION <br /> ��LLfu�i OR STREET ADDRESS ✓ bWkaU 0INDIVIDUAL O LOCAL-AGENCY D STATE-AGENCY <br /> - •Q• CORPoMTKXI = PARTNERSHIP 1:71 COUNTYIOGENCY O FEDERALAGENCY <br /> CRY NAME^ ST ZIP CODE ^520 PH NE 0 WIT A CODE — 4 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions anise. <br /> TY(TK) HO 4 4- - Q O <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE MMOD(S) USED <br /> ✓LsabirAlnY O 1 SELHNSURED 0 2 GUARANTEE7 INSURANCE O 4 SURETY BOND <br /> ED 5 LETTEROFCREDIT 0 6 EXEMPTION 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.O II. III. <br /> THIS F M HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNS ME Ip IN OWNER'S TITLE DATE ONT Y/YEAR <br /> _ e Ca, oY attL SQ <br /> _C ' <br /> 4/211 q <br /> L AL AGENCY US ONLY <br /> COUP'0 JURISDICTION I FACILITY-tit <br /> m13.1111 t 10 <br /> LOCATION CODE -OPiTONAL CENSUSTRACTI -OPT/ONAL SUPVISOR-DISTRICT CODE -OP71ONAL <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 /> FORMA(393) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR00]TAA] <br />