Laserfiche WebLink
STATEOFCAUFORMA <br /> STATE WATER WATER RESOURCES CONTROL BOARD '�I •.=c <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> •°-(IOn M- <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT <br /> O 6 CHANGE OF INFORMATION O 7 PERMANENTLY C <br /> ONE REM a 2 INTERIM PERMIT E] 4 AMENDED PERMIT <br /> Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 8 ADDRESS•VAUST BE COMPLETED) <br /> DBA OR FACILITY NAM <br /> 6L A�„�rt NAME OF OPERATOR <br /> ADDRESS /�✓ <br /> NEARESTCROSS STREET PARCEL 0(OPTONAU <br /> CITYNAME <br /> STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> ✓BOX CA <br /> TO INOCATE D CORPORATON VIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY I-D COUNTY-AGENCY• <br /> 'Npmer d UST is a public agency,oonpI gthe owing:namedS DISTRICTS• �STATE#GENCY' ED FEDERALAGENCY• <br /> N upervkar d ENkbn,seclbn.or duce which operA a IM UST <br /> TYPE OF BUSINESS O 1 OAS STATION Q 2 DISTA13UTOR M ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D. (q#Afbg <br /> Q 3 FARM Q 4 PROCESSOR 5 OTHERRESERVATION <br /> OR TRUST LANDS <br /> DAYS:NAME MSTEMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY).optional <br /> , IRST) PHONE i WITH AREA CODE <br /> A.rb ( DAYS:NAME MST,FIRSn PHONE i WITH AREA CODE <br /> I4 dl 3 -�� <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> PHONE a WITH MEA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME <br /> &I CARE OF ADDRESS INFORMATION <br /> t <br /> MAILING OR ST EET AD ✓ bm bYNkaY <br /> O INDMWAL = LCCAL-AGENCY (]STATE.AGENCY <br /> CITY NAME O CORPORATION t�PARTNEFSHP 0 COUNrV-AGENCV � FEDERAL#GENCY <br /> STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATIO •(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> !/ T <br /> MAILING Oq STRE TADDR 5 ✓�bYtlkW <br /> y INDIVIDUAL E3 LOCAL-AGENCY ED STATE-AGENCY <br /> CITY NA CORPORATIONPARTNEASRP O COUNTY-AGENCY O FEDERAL AGENCY <br /> 5`7•0e-4--`7Z:;, STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bmbAllbate O 1 SELF-INSURED "2 GUARANTEE = 3 INSURANCE <br /> D 5 LETTER OF CREDIT O 6 EXEMPTION Se OTHER 4 SURETY BOND <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 NOTIFICATIONS AND BILLING: 1.0 11.0 III O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED d SIGNED) OWNERS TITLE DATE MONTWDAVIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# - <br /> � s o b v ) H o z/�ihai <br /> LOCATgN CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 9UPVISOR-DISTRN:T <br /> y <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(3931 OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUNn OTORAGE TANK REGULATIONS <br /> FOR0303A <br />