Laserfiche WebLink
1 <br /> " to <br /> STATEOFCAUFORPNA <br /> s <br /> STATE WATER RESOURCES CONTROL BOARD s ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILffriSRE <br /> MARK ONLY Q I NEW PERMITa 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION JU T PERMANENTLY CLO <br /> ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q 5 TEMPORARY SITE CLOSURE T <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> D AORFAILITYNAME'' `P1.1I.' NAME OF OPERATOR <br /> DRESS NE RESTCRO TREET PARCEL#(OPTIONAL)9,10 <br /> CI STATE ZIP CODE ITE PHONE a WITH AREA CODE <br /> r CA ) j ,V?51 <br /> TO INDICATE ED CORPORATION C:I INDIVIDUAL ED PARTNERSHIP XLOCmAGENCY ED COUNrYAGENCY Q STATE AGENCY FEDERALAGENCY <br /> DISTTS <br /> TYPE OF BUSINESS O T GAS STATION Q 2 DISTRIBUTOR R V IF INDIAN N OF TANKS AT SITE E.P.A. I.D.i IqW naO <br /> Q 3FARM Q 4PROCESSORzi 5OTHER OR TRUST LINOS e-AH I(I II( 6&y <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> O S: NAME p T,FIRS ' PHONE 0 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE,f WITH AREA CODE <br /> VIA GI 7A <br /> NIGHTS: NAME( .FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> N •r CARE OF ADDRESS INFORMATION <br /> cun� u � t vL I Q <br /> MAI LINGO/RAT TADD S ✓ bwbiMicals Q INDIVIDUAL LOCALAGENCY 0 STATEAGENCY <br /> I '7,S Q w R� Z' I�CORPORATION =PARTNERSHIP 0 COUNTYAGENCY (]FEDERAL-AGENCY <br /> CI]f NAI�F� ST /nlsONEA W" " PHITH AREA C <br /> !L /.il fr�f J`rA/OOS� <br /> III. TANK OWNER INFORMATION- MUST BE COMPLETED <br /> N E FOW ER / a��'r�, to a CARE OF ADDRESS INFORMATION <br /> 7m bat b NANW INDIVIDUAL (LOCAL-AGENCY STATE AGENCY <br /> LArz+ IIC�FII/ CORPORATION (] PARTNERSHP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> STIZIP C90EPHONE WgH� ODE <br /> Iv Q —1��vltx) '?IV;t <br /> IV. BOARD 09 EOUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 <br /> if questions arise. <br /> TY(TK) HO 44 -1 1 _L_ <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 ABO E ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.O III.O <br /> THIS FORM HAS BEEN CPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> ILIO�SfI MZ3iNLu APPLICANTS TITLE DATE MONTWDAY R <br /> LOCAL AGENCY USE ONLY <br /> COUNTY u JURISDICTION• FACILITY It <br /> 37R 10 103 <br /> LOCATION CODE -OPTIONAL ---7S TMSUPVISOR-DIS <br /> CTi-OPTIONAL TRICT CODE -OPTIONAL <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(9-90) ( /— I C) D L/Sf/ FORONJA Rx <br /> CI' <br /> f <br />