Laserfiche WebLink
STATE OF CALIFORNIA `*_ <br /> STATE WATER RESOURCES CONTROL BOARD if <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A '�� v <br /> COMPLETE THIS FORM FOR EACH FACT ITE <br /> MARK ONLY ❑ I NEW PERMIT F73 RENEWAL PERMIT CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE <br /> I. FACIUTYISITE INFORMATION 6 ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> C57a. <br /> ADDRESS NEAREST CROSS STREET PARCELF(OPTIONAL) <br /> /30 .V , FOGY {Pv <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> c/v,T CA 9,- <br /> TOINDICx ED CORPORATION Q INDIVIDUAL Q PARTNERSHIP LOCAL-AGENCY COUNTYAGENCY STATE-AGENCY O FEDERAL40ENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR 0 ✓ IF INDIAN a OF TANKS qT SITE E.P.A. I.D.A(opkr4d) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR = 5 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) <br /> r ur .10 V &S_ 3 vS <br /> CODE- <br /> NIGHT'S: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE 4 NTH AREA COf <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME EECARE OF ADDRESS INFORMATION <br /> c5 „DRES✓ OR u r7 CU Lew <br /> MAILING OR STRTAOS / ✓ 0 INDIVIDUAL Q LOCAL-AGENCY 0 STATEAGENCY <br /> 1 !7 d- F, {j E, TNN! O PARTNERSHIP 0 COUNTYAGENOY O FEDEPALAOENCY <br /> CITU NAME 9TATE LP CODE PHONE A WITH AREA GORE <br /> G3 s w� 7-02 - Yad <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION ti <br /> MAILING OR STREET ADDRESS bm EYItlIaM INDIVWAL Q LOCAL-AGENCY Q StATEAGHICY <br /> L I- S. l S C>r1 O CORPORATION Q PARTNERSHIP a COUNTYAGENCY O FED MLAGENCY <br /> CITY NAME STAT^En ZIP CODE PHONE t WITH AREA CODE <br /> 1� T Zus Zv9- y(� <br /> IV.BOARD OF EQUAUZATI T STORAGE-FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ 4 4 4,'1' 11 sek d _ <br /> V. PETROLEUM UST FINANCIAL ONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ py binEiW O I SELF-INSURED C 2 GUARANTEE 3 INSURANCE 0 4 SURETY ODND <br /> O 5 tETTEROFCREDIT O S EXEMPTION Q 99 OTHER <br /> Vl. 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.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY)OVOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED a SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY t JURISDICTION x FACILITY# <br /> FST71 ET77 / S a <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> O/ I I- 3d <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 /> FORMA(S91) <br /> FOR0079Ad'� <br /> ..i <br />