Laserfiche WebLink
• <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i R <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A W�� ye <br /> COMPLETE THIS FORM FOR EACH FACILrTYISITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> Oak 1iI <br /> CITU NAMESTACA ZIP OpJ �a HON WITH AREA CODE t di <br /> TO I/ BOX <br /> DIIC TE 0 CORPORATION INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY El COUNTY AGENCY C:1 STATE-AGENCY [:1 FF�EDDEMLAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR 0 ✓ IF INDIAN #OF TB]yf.S,AT SITE E.P.A. I.D.#(optimal) <br /> RESERVATION /`/,�/� <br /> 3 FARM O # PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: Ni(LAST.FIRST) PHONE#WITH ARE PODE J �S: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST.7T)j PHONE#WIT AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> 1� <br /> Il. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILINGORSTREETADDRESS ✓ box Indicate O INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWI ^ ^ , ^' CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS w61-� ✓ Dox W indicate O INDIVIDUAL IO LOCAL-AGENCY 0 STATE AGENCY <br /> 0 CORPORATION O PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY <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) HQ 4 4 - a <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Eox b indicate D I SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE O A SURETY BOND <br /> D 5 LETTEROFCREOIT 6 EXEMPTION O 99 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 checked. <br /> CHECK ONE BOX INDICATING VVI-HCH ABOVE ADDRESS SHOULD SE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ it.❑ It.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY �LAvATZS <br /> COUNTY# JURISDICTION# FACIL <br /> V <br /> D <br /> LOCATION OP 71��ON��ALf�f� (CENSUS TRACT -OPTIONAL SUPVISOR-DI6TRICT COOPTIONAL <br /> THIS FORM UST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. , <br /> FORMA(5-91) • � F�7A� <br />