Laserfiche WebLink
\r• o�` <br /> STATE OF CALIFORNIA <br /> 4 <br /> ENVIRUsi�i N''TAL HEALTII STATE WATER RESOURCES CONTROL BOARD <br /> PFRM11�10INUOUND STORAGE TANK PERMIT APPLICATION - FORM A ee <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE °�r�.a`�' <br /> MARK ONLY O 3 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT Ej] 4 AMENDED PERMIT O S TEMPORARY SITE CLOSURE �--+ <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FA TY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL a(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE•WITH AREA CODE <br /> CA <br /> ✓ Box <br /> TOINDCATE [N? CORPOIMTION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY a COUNTY-AGENCY' O STATE-AGENCY' =FEDERAL AGENCY' <br /> DISTRICTS' <br /> N owner d UST Is a public agency,corrpide the following:nanle of Supervisor of d"lon,section,w opine which operates the UST <br /> TYPE OF BUSINESS O t GAS STATION 0 2 DISTRIBUTOR 0 ✓ IF INDIAN a OF TANKS AT SITE E.P.A I.D.a(%VAMAO <br /> 0 3 FARM = 4 PROCESSOR OR <br /> OTHER RESERVATION <br /> TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE At WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> 7] <br /> N NAM T.FIRS PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA COOS <br /> a <br /> 11. PROPERTY OWNER IN RMATION• MUST BE COMPLETED <br /> NAME RE OF ADDRESS INFORMAT N <br /> MAILINGORSTR ADDRESS4 ✓ xbifdkale (] INDIVIDUAL Q LOCAL-AGENCY O STATE-AGENCY <br /> ORPoRARON 0 PARTNERSHIP =COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITU NAME ST TE ZIP CODE PHONE a WITH AfR-EA CODE <br /> 7 —575 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME NER C� E OF ADDRESS INFORMATION o <br /> MAILIN R 3TRE ADDRESS ✓✓)/Dqx ID micab � INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> L]QCORPORATION =PARTNERSHIP O COUNTYAGENCY D FEDERAL-AGENCY <br /> CITY N STATE 21P CODE PHONE a WITH AREA CODE <br /> 1 <br /> IV.BOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-14--] v k y L �.0-1-i-T <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓boxickd we T SELF-INSURED Q 2 GUARANTEE 3 INSURANCE L-j 4 SUREIYBOND <br /> =5 LETTEROFCREDIT b EXEMPTION (] 0 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 IL O 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) OWNER'S TITLE DATE MONTWDAY/YEAR <br /> r <br /> im mew, I 1-5-95 <br /> LOCAL AGENCY USE ONLY) <br /> COUNTY C JURISDICTION S FACLLrTY t <br /> LOCATION CODE -OPTX)AML CENSUS TRACTe -OPTIONAL SUPVISOR-DNi C5 17 TKXINL <br /> �, <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(3'93) FORMM-97 <br />