Laserfiche WebLink
•�go�- ea <br /> STATE OF CALIFORNIA c <br /> STATE WATER RESOURCES CONTROL BOARD i m� y <br /> �ERGROUND STORAGE TANK PERMIT APPLICATION-FORM A e <br /> COMPLETE THIS FORM FOR EACH ILITYISITE <br /> MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 1—j 7 PERMANENTLY CLO E <br /> ONE REM Q 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY E NAME OF OPEJqATOR <br /> U l ..IUn PS <br /> ADDRESS - NEAREST CROSS STREET PARCEL*(OPTIONAL) <br /> /rL �✓ <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> S Ca Zv - Yb3-5-3 <br /> TOBoxINDICATE =COR = INDIVIDUAL (]PARTNERSHIP O LLOCAL-AGENDISTRCY COUNTY�AGENCY l�SrATE-AGENCY L FEDEML#GENCY <br /> TYPE OF BUSINESS T GAS STATION 0 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(0pIAxmN) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR Q & 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) PHONE#WITH AREA CODE <br /> nOli , - Yb iS3 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> r vu U 99 <br /> MAILING OR STREET ADDRESS ✓ bo.0 kwbab 0 INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> O CORPORATION = PARTNERSHIP O COUNTY-AGENCY D FEDERALAGENCY <br /> CITY NAMESTATE ZIP CODE P E#WITH AREA CODE J� <br /> SGfm �/'u NC/SC" C4D S I 1O �,]T <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS box bkld D INDIVIDUAL O UXAI.AGENCY M STATE AGENCY <br /> I�CORPORATION O PARTNERSHIP COUNTY-AGENCY O FEDERAL#GENCY <br /> CITY NAME STATE ZIP CODE PHONE-#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)739-2582 if questions arise. <br /> TY(TK) HQ F4-F4]- <br /> p 2 S <br /> V. 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 II.O HL O <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) APPLK)ANTS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# C(./EI(/�PO.S <br /> LOCATION CODE -OP77ONAL CENSUS TRACT*-OPTIONAL SUPVISOR-DISTRICT CODE -OPTN3NAL <br /> a / <br /> -z-3 3Z <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFOR TION ONLY. <br /> FORM A(8 W) <br /> ANi2 <br />