Laserfiche WebLink
� la,bOUR ! f <br /> STATE OF CALIFORNIA ,,' b <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� �e <br /> ... . <br /> 0 <br /> ��URN,� <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED. <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA'I FAC TY NAM NAME OF OPERATOR <br /> vc, <br /> ADDR S NEAREST CROSS STREET PARCEL*(OPTIONAL)lv_ <br /> CI M STATE ZIP C .r�o.3 SITE PHONE#WITH AREA CODE <br /> I/ Box <br /> CA y <br /> TO INDICATE O CORPORATION INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY (] STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ qE/ IF INDIAN <br /> A OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> ❑ 3 FARM ❑ ATIO <br /> < PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIR Sn PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COQF <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bov bgMicab = INDIVIDUAL O LOCAL-AGENCY O STATE AGENCY <br /> O CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> IN <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATI N-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS- ✓ SOobladica =1 INDIVIDUAL O LOCAL-AGENCY STATE AGENCY <br /> O CORPORATION Q PARTNERSHIP O COUNTY-AGENCY FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO L4L4 OZ &} 5 8 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COIII—IDENTIFY THE METHOD(S) USED <br /> ✓ Eov bintlbale 1 SELF-INSUREDO GUARANTEE 0 3INSURANCE 01 SU POND <br /> 5 LETTEROFCREIXT 6 EXEMPTION IS 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 ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L[— <br /> j II.v <br /> IIL❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# S JURISDIC.TION# FACILITY# <br /> L �I/GLIVE ,00 _ S ' <br /> LOCATION D OPT 10 NAL KENS TT# C -OPTIONAL <br /> Yy✓� <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(1z st) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> \ � FOR00]]AR6 <br />