Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> �JAI9ERGROUND STORAGE TANK PERMIT APPLICATION- FORM A y a <br /> Y/ 0 <br /> COMPLETE THIS FORM FOR EACH ITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENT CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> NAME Of OPERATOR <br /> ADDRESS u <br /> _ NEAREST CROSS STREET PARCELO(OPT <br /> CITY NAME <br /> STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> s l CA - z <br /> ✓ BOX <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q OOUNTYAGENDY QSTATE-AGENCY Q FFDEML-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR Q ✓ IF INDIAN I#OF TANKS AT SITE E.P.A L D.#(cpftm q <br /> 0 3 FARM Q a PROCESSOR = 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 DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST.FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box 0wd,:2e0 Q INDIVIDUAL Q LOCAL.AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHP Q COUNIYAGENCY Q FEOEM AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> lit. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ WX A,mO Q INDIVIDUAL Q LOCAL-AGENCY Q STATE AGESCY <br /> Q CORPORATION Q PARTNERS14P Q COUNTY-AGENCY Q FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 0 WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HO F4-1-4]- 3 a a <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ 5u�n IMKau Q I SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q X SUnEIV BOND <br /> Q 5 ILTTEROFCREDIT Q 6 E%EMPTION Q 99 OTHER <br /> 771 <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or IN is checked. <br /> CHECK ONE BOX INDICATING WHICH MOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L O II.❑ IN.❑ <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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# - FACILITY# S?A Ng/S <br /> LOCATION CODE -OPTDAML CENSUS TRACT$ •OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 0 a36�D 3? 3 3 <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE W ON ONLY. <br /> FORM A(5-91) , FOROW]A5 <br /> %WW V <br />