Laserfiche WebLink
tib- C <br /> STATEOFCAUFORNIA - ` <br /> STATE WATER RESOURCES CONTROL BOARD ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A 5�ffi o <br /> COMPLETE THIS FORM FOR EACH FACILTTYISITE `'L�•e-+" <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O T PERMANEN SED SITE <br /> ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT # TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OB&AB FACILITY NAME NAMED ERATOR - <br /> CJXA � c <br /> AODPIMS NEARE TCROSS ST EET PARCEL*(OPTIONAL) <br /> CITY E STATE ZIPCODE SITE PHONE a WITH AREA CODE <br /> CA <br /> BOX <br /> TOINDICATE O CORPORATION INDNIWAL O PARTNERSHP LOCALA S�Y COUNTY AGENCY STATE-AGENCY' C FEDEML#GEWY' <br /> I owner W UST Is a puNIC agency.cvrnpete ft following:nerne of Supevwor of dNYlon,sechon,W office wN ch operates Ne UST <br /> TYPE OF BUSINESS t GAS STATION Q 2 DISTRIBUTOR 0 ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.#(gxwa/) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional - <br /> DAV NAME(LAST,FIRST) PHONE#WI H EA CODE DAYS: NAME(LAST,FIRS PHONE a WITH AREA CODE <br /> Q <br /> N TS: NAME(LAST,FIR-4 _,PtpNE a WITH AREA CODE I NIGHTS; (LAST,FIRST) PHbNE*WITH AREA CODE <br /> e <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME ` CARE OF ADDRESS INFORMATION <br /> MAILING ST <br /> OR REET DRESS '� los bl#ieaM IC INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> �, C CORPORATION = PARTNERSHIP O COUNTY AGENCY C FEDERAL AGENCY <br /> CITY NAMST TE ZIP DE �� PHONE a WITH AREA CODE <br /> III. TANK 0 NER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STR TADDRESS J W.wmk C INDIVIDUAL LOCAL AGENCY STATE AGENCY <br /> C CORPORATION C PARTNERSHIP O COUNTY AGENCY FEDEMLAGENCY <br /> CIT'NAME - STATE ZIP CODE PHONE a 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_T4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Im vidkals C) I SELF INSURED C 2 GUARANTEE C 3 INSURANCE IC 4 SURETY D <br /> C 5 LETTER OF CREDIT s E%EmFnoN C) 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless o is checked. <br /> CHECKONE BOJ(INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II-EJ ill. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY t <br /> nal 2Uv 121311 151ZEL <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 9UPVISOR-DISTRICT CODE -OPTIOAML <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFoRmATI6N OILY. <br /> FORMA <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> (39:1) FORDMI&M <br />