Laserfiche WebLink
STATE OF CALIFORNIA <br /> o <br /> /) STATE WATER RESOURCES CONTROL BOARD W off' Ae a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A 'o <br /> COMPLETE THIS FORM FOR EACH FACILrTYISITE <br /> MARK ONLY O 1 NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED_SITE-- <br /> ) <br /> ONE ITEM 2 INTERIM PERMIT E:] 4 AMENDED PERMIT Q S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME ` J�Q NAMEOFOPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCELa(OPrIONAU <br /> 209 • L%-AAA mvvte� k-o.�t <br /> CITU NAME � STATE ZIP CODE 517E PHONE#WITH AREA CODE <br /> CA 1 9 Z'='9 <br /> T 10 NDBox �CORPORATION �INDIVIDUAL �PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' STATE-AGENCY' O FEDERAL-AGFNCY' <br /> DSTRICTS' <br /> •I owner d UST Is a public agency,complete the blowing:name of Supervisor of tlNMbn,s9atun,n oaiw which apendes the UST <br /> TYPE OF BUSINESS O ) GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN 19 OF TANKS AT SITE E.P.AL L D.#Igpa.ag <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR F, 5 OTHER OR TRUST LANDS ' - <br /> EMERGENCYCONTACTPERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRSTI PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME ��\T-(VS 1 , CARE OF ADDRESS INFORMATION <br /> vvC . <br /> MAILING OR STREET ADDRESS ('1 .1bulo dcals [:j INDIVIDUAL 0 LOCAL-AGENCY E-1STATE-AGENCY <br /> YC7 comt_� GA ort Olgcr ,>1'e AS-S MCORPORATION 0 PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP DE PHONE a WITH AREA CODE <br /> San Cr, vS�3 Sl0- a7 -otfr <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> m C__ —�— <br /> MAILING ORSTREET ADDRESS ✓box b lnAnum = INDIVIDUAL ED LOCAL AGENCY STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNry-ADENCY Ell FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questlons arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓bm bYgkale 0 1 SELF INSURED O 2 GUARANTEE 3 INSURANCE O 4 SURETY BOND <br /> D 5 LETTEROFCREDT 041 EXEMPTION W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless Lx I or II is ch d. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: - I.K71 II. III.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,TS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNERSTITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m 2431zl6 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OPWA14L SUPV190R- THICT CODE -OPTIONAL <br /> �z— 098— 5-23-yy <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 THE FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKW <br /> FORM A(393) FLX1MMA7 <br />