Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ;y,,,� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , <br /> COMPLETE THIS FORM FOR EACH FACILITYIS[TE <br /> MARK ONLY ® 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO <br /> ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT E::] e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF ERATOR <br /> UlMGo 7aclrz <br /> -OCk P ,4 0L-OPMPIAIJ <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 10 22 F/[oFO7-ACvE- K0 JACK ZoAI 2p 26(- oZo - 04 <br /> CITY NAME STATE ZIP CODE SITE PHONE R WITH AREA CODE <br /> �?—I Pbl�) CA 7-01— S9Q—2 1 1 1 <br /> ✓BOX Q CORPORATION O INDIVIDUAL PARTNERSHIP C:]LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' D FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> #awnarof UST40Pubkagenry,mm wie Ne MlMwna rem#of supervisorof division,saacn or o#Ne which 4 OWN the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR RESV IF INDIAN ERVATION #OF TANKS AT SITE I E P.A. I.D.#(Wit ml) <br /> Q 3FARM Q 4PROCESSOR Q 5OTHER OR TRUST LANDS 3 caL_ 000 Isa: y'GS <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 /> 611fI TIM L' zoq— q31 -4511 D✓/�cf(A/A Hl2ur1 2Oq-Sdq -2112 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> SAME SAMA <br /> II. PROPERTY OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> OL In PI Rn) <br /> MAILING OR STREET ADDRESS C ✓ box to axkmO INDNIDIIAL O LOCAL-AGENCY O STATE-AGENCY <br /> 2,10c> M CK�LUF CT O CORPORATION jjjrPARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STAT ZIP COD��O PHONE 620WITH SgqCODE 46517 <br /> S. 5 A-+.1 F/1ArO C t S c a CC�� CC��''ff <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 5AME ArS 1� <br /> MAILING OR STREET ADDRESS ✓ box Iondirale Q NDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#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-[4--] <br /> 0 0 2 4 g S <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bos 1°IMrate 1 SELF-INSURED O 2 GUARANTEE O 3 INSURANCE =4 SURETY BOND O 5 LETTER OF CREDIT ED 6 EXEMPTION CN7 STATEFUND <br /> D6STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FIND&CERTIFICATEOF DEPOSIT O10LOCAL GOVT.MECHANISM O99OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.1��- III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANKOWNER'S NAME(PRINT SI N TUR TANK OWNER'S TRLE ,�- DATE MONTWDAYNEAR <br /> MIK L� ATGCvf POT 10159 ON&,(, <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 0 JURISDICTION# FACILITY#Q(b 7/7 <br /> m1,213 11 1& 10 1 Z 4 L <br /> LOCATION CODE-OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISDR-DISTRICT CODE -OPITONAL <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(6.95) / I /1,- /r <br />