Laserfiche WebLink
moon es <br /> STATE OF CALIFORNIA 'we .` ,-•'• eo <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A oa <br /> COMPLETE THIS FORM FOR EACH FA ISRE <br /> MARK ONLY t NEW PERMIT O 3 RENEWAL PERMIT5 CHANGE OF INFORMATION 0 7 PERMANENT DSR <br /> ONE REM Q 2 INTERIM PERMIT Q A AMENDED PERMIT E�] S TEMPORARY SITE CLOSURE S <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL (OPTONAp <br /> CITY NAME / STATE 21P CODE SITE PHONES WITH AREA CODE <br /> S/p uGf3�7 CA <br /> TOIN ICABOX Q CORPORATION INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY <br /> OCAL-DISTRG CY Q COUNTY-AGENCY Q STATE AGENCY Q FEDERAL-AGENCY <br /> rS <br /> TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTOR Q RE-/ IF INDIAN SERVATION #OF TANKS AT SITE I E.P.A I.D.#(oplbrw/) <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRSC PHONE s WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> /91Q 'g>G S <br /> MAILING OR STREET ADDRESS ✓ box bintlbaN Q INDIVIDUAL Q LOCALAGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS bw 0 Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERS14P Q COUNTY-AGENCY Q FEDERAL-AGENCY <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 -16131 d 1,4 > {. <br /> V. 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: I.O 11.Q III.Q <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 TIRE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION III FACILITY! BA�� a9 <br /> 1 tl '71 FF S- 7 <br /> LOCATION CODE -OP"�7iO�N�A'�LI�' S TRACT-OPTIONAL 9UPVISOR-DISTRICT CODE -OPTIONAL <br /> CENSU <br /> o� c? 3n 3 3 co79 <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 /> FORW]9AR2 <br /> FORM A(9 90) <br />