Laserfiche WebLink
STATE OF CALIFORNIA �� i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� ' <br /> . , o <br /> COMPLETE THIS FORM FOR EACH FACILrTY/SITE `a' o4i a �;. <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILfTY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> nPA 04 FA I-ITY NAME _ <br /> NAME OF OPERATOR <br /> A:� <br /> ADDRESS <br /> L(4N� ST CROs STREET PARCELa(OPrpNAIJ <br /> S. L GG„)) <br /> 1210.1> <br /> CITY NAME <br /> 5 STATE ZIP CODE HONE A WITH AREA CODE <br /> I/Box CA SZ 1c37- DF)6 <br /> TO NDICATE O CORPORATION IJV INDIVIDUAL O PARTNERSNIP LOCAL-AGENCY O COUNTYAGENCY' O STATE-AGENCY' O FERAL.AGENCY' <br /> N a w of UST is a plc agency,Wrrplae the 101OWn :name of S DISTRICTS' <br /> g uparvisor of ENYbn,aeclbn,or oNin which operates the UST <br /> TYPEOF BUSINESS 1 GAS STATION O 2 DISTRIBUTORI' A IF INDIAN OF TANKS AT SITE E.P.A. I.D.a(aptbW <br /> O 3 FARM O PROCESSOR 5 OTHER O RESERVATION <br /> 4 <br /> ❑ OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST} PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> Lj w1 ao <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> n n U? D-386/ <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAM ,s Q CAC(JOE ADDRESS INFOR TION Q� ('777 <br /> - �aA�s ( Gb Zib 1 <br /> MAILING OR STREET ADDRESS / ✓ Ooa blMbaw [�'RIBIVIDUAL O LOCAL-AGENCY STATE.AGENCY <br /> CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERALAGENCY <br /> �Itt NAME y - -- STA ZIP COD�Ej PH'ONwEa WITH APER CODE �f <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa b9tlbaa INDIVIDUAL E:] LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION (] PARTNERSHIP 0 COUNTY.AGENCY O FEDERALAGENCY <br /> CRY NAME STATE 21P CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(9 16)322.9669 if questions arise. <br /> TY(TK) HQ [4T4--]- <br /> V. PETROLEUM LISTFINANCIA RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THEMETHOD(S) USED <br /> ✓Saa byre 1 SELF-INSURED =2 GUARANTEE I�]INSURANCE 0 4 SUREIYBOND <br /> Ez;H <br /> O 5 LETrEROFCREDIT =5 EXEMPTION D 99 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ II.[;?I" IN.O <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 a SIGNED) OWNERS TITLE DATE MONTWDAY/YEAR <br /> ✓ v s/ <br /> LOCAL AGENCY USE ONLY <br /> COUNTY A JURISDICTION a FACILrTY• <br /> m <br /> LOCATION CODE -OPTIONAL (CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PER MR APPLICATION• FORM Br 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 /> FORMA(3931 '011=3A 87 <br />