Laserfiche WebLink
•,b UR � <br /> STATE OF CALIFORNIA e i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> oar;. <br /> COMPLETE THIS FORM FOR EACH FACILrTY/SITE 9 :;' LLam�,,� <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 1'7`- sR�MAS1EfJ Y�QL( IT <br /> ONE REM Q 2 INTERIM PERMIT F--] 4 AMENDED PERMIT O a TEMPORARY SITE CLOSURE 44ii <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 992 ��P�ff►►A <br /> DBAO FACILITY AME' NAME OF OPERATOR ' -. ll1VI f <br /> P HEALTH <br /> S w rvC <br /> ADTTL - I DVJ a NEAREST T`CROSS��0 PARCEL#10 <br /> PTIMALT <br /> CITU NAME STATE �i ZIP CODs ITE NE s WITH AREA CODE <br /> S til CA % 20S _ 5500 <br /> I/ BOX <br /> TO INDICATE I CORPORATION WIDUAL I�PARTNERSHIP 0 LOCAL-AGENCY 0 COLINTYAGENGY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 GAS STATION Q 2 DISTRIBUTOR O ,/ IF INDIAN s OF TANKS AT SITE E.P.A. I.D.s(OPAi 1) <br /> RESERVATION <br /> 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> R - 00 <br /> NIGHTS: NAM (LAST.FIT) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE w WITH AREA COOP <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> 7SW; 1; P. CARE OF ADDRESS INFORMATION <br /> MILIN OR STREET ADDRESS ✓ boxbindkMm EP INDIVIDUAL Q LOCAL AGENCY STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP (]COUNTY-AGENCY Q FEDERALAGENCY <br /> CITU AME cX 1 V STATE 21P DE V J P710 5En# ITH AREA CODE <br /> TEO <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) C'1' V CC#+�( <br /> NAMEOFO NER' CARE OF ADDRESS INFORMATION <br /> � TN <br /> MAILING OCR STREETADDRESnSn btbi0kate NIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> 8 J �, 1�/Q CORPORATION O PARTNERSHIP (] COUNTY AGENCY Q REDERALAGENCY <br /> CITY NAME ` STATE ZIP CODE PHONE s_ ITH AREA WICO <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 0 3 6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓bm bindkae O I SELF-INSURED O 2 GUARANTEE0 9 1 ANCE (]4 SURETY BOND <br /> D 5 LETTEROFCREDR D 6 EXEMPTION OTHER <br /> 71 <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is c ed. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLIC NTS NAME(P INTEO a SIGNATURE APPLICANT'S TIT E DATE MONT V/YEAR <br /> E i Z /D A� <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILrY# Gt50)rS17 <br /> a <br /> CLOCATIONdD -OPTIONAL TRAa d1" SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 3 a-3 <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 /> FORM A(5.91) FOR0037A5 <br />