Laserfiche WebLink
rca " r <br /> STATE OF CALIFORNIA er <br /> STATE WATER RESOURCES CONTROL BOARD i ei� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE rQVpeY�- <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT E::] e AMENDED PERMIT 0 e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DPA OR FACILITY NAME L NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPrIONAU <br /> /Z O � 38a_ <br /> CITY NAME OG � STATE ZIP CODE BITE PHONE i WITH AREA <br /> I/ BOX <br /> TO INDICATE CORPORATION 0 INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY CWNrYAGENCY' ED STATE-AGENCY' = FEDEHAL#GENCY' <br /> DISTRICTS' <br /> If owner of UST Is a public agency,complete the tollowing:naris of Supervisor of division,Section,or duce which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR Q 7' IF INDIAN i OF TANKS AT SITE E.P.A. I.D.i(clotio al) <br /> RESERVATION <br /> 3 FARM Q A PROCESSOR 5 OTHER Oq TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY NAME(LAST,FIRST) PHONE i WITH AREA DAYS: NAME(LAST,FIRST) PHONE S WITH AREA <br /> CODE <br /> 2i n <br /> NIGHTS: NAME(VST,FIRST) PHONE i WITH AREA DE NIGHTS: NAME(LAST.FIRST) PHONES WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> :5i21110—:5i21110—Bvi!,o/ Sf �' q ��+r74md-CECo CtW _5-, s A6gz <br /> MAILI ORSTREET ADDRESS ✓ bnrbYtlkals 0 INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY <br /> Q. &ox z�jg CORPORATION O PARTNERSHIP E::]COUKrYAGENCY E-1FEDERAL-AGENCY <br /> iCITY NAME ` � I STATE ZIP CODE — PHONE S WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Om Uv/LA/ STI�/r'7 <br /> MAILINGOR STREET ADDRESS ✓borbirmll O INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> Z/Q/ E. =CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE S WITH AREA CODE <br /> IV.BOARD OF EOUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ ba bNNkW Q I SELF-INSURED Q 2 GUARANTEE 3INSURANCE O A SURETYBOND <br /> O 5 LETTEROFCREDR O S EXEMPTION O aS 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: I.O I.x <br /> III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND dORRECT <br /> OWNERS NAME(PRINTED S SIGNED) OWNERS TRLE DATE MONTHADAYNEAR <br /> LOCAL AGENCY USE ONLY pR jpo <br /> COUNTY# JURISDICTION♦ FACILITY IIIm Fm _ <br /> �I <br /> LOCATION CODE -OPTIO L CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> b <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE SITE iNFbRmATiON ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3W) FORMU R7 <br />