Laserfiche WebLink
STATE OF CALIFORNIA ^���'' •" <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION y • FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE o, <br /> MARK ONLY ❑ NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DB R A LITY N.6ME NAMEOFOSE <br /> ADD REB NEAR CROSS PARCEL#(OPrONAL) <br /> CITY <br /> 9 (`CpmT TE ZIP �vV SITE PHONE a WITH AREA CODE <br /> CA Y <br /> TO INDICATE 0 CORPORATION 0 INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTYAGENCV' O STATE-AGENCY' O FEDERALAMNCY- <br /> 'I caner Of UST is a public agency.OOrnPIM the Iolicadn :nama of S DISTRICTS' <br /> p upervior of tlM4bn,sectbn,Or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN IN OF T AT SITE E.P.A. I.D.a(opim") <br /> ❑ TION <br /> 3 FARM Q 4 PROCESSOR 5 OTHER O TRUSTRESERANDS <br /> ❑ OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE i 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 a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bot biMkab INDIVDUAL O IACA4AGENCY 0 STATE-AGENCY <br /> CORPORATION = PARTNERSHIP O COUNTYAGENCY 0 FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box O dices O INDIVIDUAL LOCAL-AGENCY (] STATE-AGENCY <br /> D CORPORATION O PARTNERSHIP 0 COUNTYAGENCY 0 FEDERALAGENCY <br /> CITY NAME BTATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HO 4 4- - Q 2 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE CO LETED)—IDENTIFY THE METHOD(S) USED <br /> ✓be,bXlSede (� 1 SELFINSURED GUARANTEE D 3 INSURANCE ED 4 SURETY BOND <br /> 5 LETTER OF CREDIT &EXEMPTION O 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.Q it.Q III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION• FACILITY I .k13 <br /> LOCATION E -OPTIONAL CENSUS TRACT#-OiLSUPVISDR-MT -OPTIONAL / <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNL SS 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(3'93) FORDW3AAt <br />