Laserfiche WebLink
i <br /> STATE OF CALIFORNIA <br /> ♦ �i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANE LY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT & TEMPORARY SITE CLOSURE ''- <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA ORF UTY NAME / NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPFIONAL) <br /> S 86v-5 �,�o S' <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> CA 5'3 <br /> BOX <br /> TO INDICATE Q CORPORATICIIII CORPORA0 INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNrY-AGENCY Q STATE-AGENCY Q FFDEPAL-AGENCY <br /> DISTRICTS <br /> .TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR = PE$EpypTDIIAN ON A OF TANKS AT SITE E.P.A. L D.A(oWWW) <br /> O 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE-7 AYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA COCF <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bo,timiaw Q INDIVIDUAL Q LOCAL-AGFRCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-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 /> MAILING OR STREET ADDRESS ✓ Emtinaim Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY.AGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 it questions arise. <br /> TY(TK) HO 4 4 -IU 2 6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ ba 0mdt Q I SELF-INSURED Q 2 GUARANTEE 0,�,,O—.ar3�'� InINSURANCE Q 4 SUR <br /> L_ ETY BOND <br /> O 5 LETTERCFCREOIT O S EXEMPTION O [R <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 ASOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ IL❑ In.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY[0 �S�j D JURISDICTION <br /> a FACILITY9 <br /> U <br /> LOCATION CODE -OPTIONAL (CENSUS TilAG2a -OPTIONAL 5� SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 9 Z (JN <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5911 � FIXi50]b5 <br />