Laserfiche WebLink
" f9 <br /> STATE OF CAUPoRMA <br /> STATE WATER RESOURCES CONTROL BOARD sy <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EAC ACILrTYISrrE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT I❑ a AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE 53 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> n_ U Club 1b NAME OF OPERATOR <br /> kjkhorn ADDRESS w ,f! V N EST CROSS STREET PARCELI(OPfgNAy <br /> 5 I K orn Drtve- a )s <br /> CITXWME �� STATE ZIP °9 <br /> p <br /> ✓Box PHONE aWITH AREA CODE <br /> CA 2 <br /> TO INDICATE p CORPORATION p INDIVIDUAL p PARTNERSHIP p LOCAL-AGENCY p COUNTY-AGENCY p STATE.AGENCY p FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ ) GAS STATION ❑ 2 DISTRIBUTORO ✓ IF INDIAN A OF TANKS AT SITE E.P.A. L D.•F.—O-403 FARM A PROCESSOR 5 OTHER RESERVATION <br /> ❑ ❑ OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST) PHONE t WITH AREA CODE GAYS: NAME(LAST,FIRST) PHONESWIIIETHAREACOODX <br /> NIGHTS:NAME(LAST,FIRST) PHONE s WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHON <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESSINFORMATION <br /> MAILING OR STREET ADDRESS ✓ Om bYMkw p INDIVIDUAL p LOCAL AGENCY p STATE- <br /> AGENCY <br /> p CORPORATION p PARTNERSHIP p COUNTYAGENCY p FEDEAALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA COOS <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS Em bYtlkalA p INDIVIDUAL p LOCAL.AGENCY p STATEAGENCY <br /> p CORPORATION p PARTNERSHIP p COUNTYAGEMCY p FEDERALAWNCY <br /> CITY NAME STATE ZIP CODE PHONE•WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 -� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or itis checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.O III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHrDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUN^Y N C.Y:u-r #F JURISDICTION• FACILITY✓< <br /> ELK H D I O 5)'Ze <br /> LOCATION CODEi 7gNAL CENSUS TRACTAOPTIONAL SUP 7 j-DISTRICT CODE -OPT L12 <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 /> FORM A(S-S0) /� 1 FOROW3A R2 <br />