Laserfiche WebLink
eeo�• <br /> STATE OF CALIFORNIA s <br /> STATE WATER RESOURCES CONTROL BOARD fe - <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH CILrTYISITE <br /> MARK ONLY NEW PERMIT S RENEWAL PERMIT S CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT �i 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE S� <br /> I. FACILITY/SITE INFORMATION & ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> FJ'lt lC <br /> ADDRESS NEAREST CROSSSTREET PARCEL 1OPION01) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> S c(� fx ti CA s 7c) /Box <br /> TO DICATE O CORPORATION ED INDIVIDUALPARTNERSHP Q LOCAL-AGENCY (]COUNTYAGENCY Q STATE-AGENCY <br /> DSTRICTS D FEDERµ.AGENCY <br /> TYPE OF BUSINESS O L GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.#Iaprio W) <br /> I� 3 FARM O 0 PROCESSOR S OTHER ORRESRVATION <br /> ETRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE s WITH AREACODE DAYS: NAME MST,FIRST) <br /> a�,,-4 Sud avy-Kos-G3d3 PWnNg WT. <br /> NIGHTS: NA E(LAST,FI ST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME ( f rj p r-c CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS p '/NMbmM ED INDIVIDUAL Q LOCALAGENCY STATE-AGENCY <br /> S �� r 0.1# l s2 D Y O CORPONAnON ED PARTNERSHIP p COUNTYAGENCY ED FEDERAL-AGENCY <br /> CITY NAME ) f H yO STa ZIP CODE PHONE s WITH AREA CODE <br /> R a <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Nml butlKLB INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY.AGENCY = FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EOUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323.9555 B questions arise. <br /> TY(TK) HO 4 4 - p a (o <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Eea bilSMb O ( SELI-INSURED 2 GUARANTEE E3 7 MURMICE A SURETY BOND <br /> 5 LETTER OF CREDT S IXEMPTION 0 a OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is ched. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L a IL III!= <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> C�OD�� UTY�NTY# JURISDICTION# FACILITY# QLJTC.F_ Q_ <br /> J U E= / /Tyrvi <br /> LOCATION CODE -OPTIONAL (CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> a 3 01D 0-0 3a t 2-0 Z_ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(EBt) F5 <br />