Laserfiche WebLink
0 <br /> e V- <br /> STATEOFCAUFOgWA �' •• w <br /> ® STATE WATER RESOURCES CONTROL BOARD i 'o, <br /> i All UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 'u� ': <br /> . . <br /> 4101— COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> ARK ONLY (Cy I NEW PERMIT O 3 RENEWAL PERMIT '� 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLO13EEDD <br /> SITE <br /> ONErEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT & TEMPORARY SITE CLOSURE <br /> tjR <br /> TE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> E NAMEOFOPERATOR <br /> 10 <br /> Q ,^_It z <br /> NE E TCROSSSTREET PARCEL/(OWgNAU <br /> • j''I ST CA. ZIP SITE PHONE a WITH AREA CODE <br /> CORPORATIONINDIVIDUAL O PARTNEASIAP = LOCAL-AGENCY O CWMY-AAGENCY' O STATE-AGENCY' OFEGEML#GENCY' <br /> '10w,9111 UST k a public ag"CY,Complete the following:narne of Supervisor of division,section,or officewhichoperates the UST <br /> / TYPE OF BUSINESS O f GAS STATION Q 2 DISTgIBUTOR ✓ t INDIAN #OF TANKS AT SITE E.P.A. I.D.#(apliarwj <br /> I 13 FARM Q 4 PROCESSOR 5 OTHER a RESERVATION <br /> OR TRUST LANDS <br /> / EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlon/I <br /> E(LAST,FIRST) Chao lec,PHONE#WITH AREA CODE DAYS:NAME MST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAS1jfFIRS10 PHIJINE.JIVIIHAREACOICh NIGHTS: NAME(LAST,FIRST) -PHONE#WITH AREA CODE <br /> II, PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME n CAR <br /> E OF R INFORMATIO <br /> 1n r nz <br /> MAILING OR STREET ADDR ✓ b (� INDIVIDUAL I� LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION =PARTNERSHIP O COUNTYAGENCY O FEDERAL-AGENCY <br /> C NAME /f8�T'µl ZIP Cr <br /> III. TANK OWNER INFORMATION.(MUST BE COMPLETED) <br /> [/Y <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boabimica, l= INDIVIDUAL Q LOCAL AGENCY Q SrATE-AGENCY <br /> CORPORATION M PARTNERSHIP 0 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)322.9669 if questions arise. <br /> TY(TK) HQ 14141- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓b„bintcN. Q f SELF-INSURED O 2 GUARANTEE [=1 3 INSURANCE O A SURETY BOND <br /> D 5 LETTER OF CREDIT Q&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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 11.- 111.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> DIANE R'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION t FACILITY! <br /> v-'--/ <br /> LOCATION CODE -OPTIONAL CENSUSTMC •OP K)NAL– RRffr- <br /> SUPVISOFL-DlSfFfCT •OP <br /> C i <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM13m us-tHeISA CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) 11 C.7 /, /�A FOR0031AA'/ <br />