Laserfiche WebLink
NOW ..i <br /> �yoen : <o <br /> STATE OF CALIFORNIA „'^ <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A "� as <br /> 1' ^ /i y�'n- ' <br /> J4 COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY LJ I NEW PERMIT ❑ S RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION III ADDRESS•(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME O ,� NAME OF OPERATOR <br /> ADORES NEAREST CROSS STREET PARCEL/(OPTIONAL) <br /> i a �. � _ <br /> a I' b <br /> CITY NAME O STAZIP 5SITE PHONES,ITHA+EAC. <br /> CA ?a 0 <br /> v BOX <br /> T INDICATE Q CORPORATION INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE AGENCY 1O !pQ FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Q I GAS STATION Q 2 DISTRIBUTOR RESERVATION <br /> VIF INDIAN <br /> a OF TANKS AT SITE E.P.A. 1.0.a(Optimal) <br /> FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE;1 TH AARE;CODE DAYS:NAME(LAST,FIRST) <br /> e Cao ✓WPHONE A WITH AREA�, g <br /> NIG S: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> SaNnit� <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME Am �R� CARE OF ADDRESS INFORMATION <br /> MAILING ORSTREETADDRESS v, box 0A*k Q INDIVIDUAL Q LOCAL AGENCY Q STATE AGENCY <br /> da Q CORPORATION ERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATES <br /> ICA ZIP QOM �O F� ITH AREA��—CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) gl SCJ CP(J <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box 0 Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSIOP Q COUNrY.AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HO 44 - Q o� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Wx bim"m IQ 1 SELF-INSURED i0 2 GUARANTEES <br /> SU EA' <br /> Q 4 SURETYBOND <br /> Q 5 LETTEROFCREOT Q 6 EXEMPTION OTHER /JO'7t 0-- <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 NOTIFCATIONS AND BILLING: I.O IL. K 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(PRNTED 6 SIGNATURE) APPLICANT'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION a FAC <br /> LOCATION CODE -OP77OWL CENSUS Tf1ACT. -OPTrowu SUPVISOR RIOT-D CO E -OPTNJNAL <br /> O"ll a <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(5-91) _ FOnOWAA 5 <br />