Laserfiche WebLink
• P�' a CEJ <br /> STATE OF CALIFORNIA b <br /> STATE WATER RESOURCES CONTROL BOARD 3 , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A o= <br /> COMPLETE THIS FORM FOR EACH F CILITYISITE <br /> MARK ONLY Ll 1 NEW PERMIT F7 3 RENEWAL PERMIT 2frS CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM E] 2 INTERIM PERMIT " 4 AMENDED PERMIT D 6 TEMPORARY SITE CLOSURE <br /> t. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DRA OR FACT ITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> CITY NAME STATE ZIP CO ? i SITE PHONE#WITH AREA CODE <br /> ✓ BOX <br /> TO INDICATE C�CORPORATION E7, INDIVIDUAL l� 'PARTNERSHIP OLOCAL-AGENCY [� COUNTY-AGENCY 0STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS L__] 1 GAS STATION [] 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.R A. I.D.#(Wiana)) <br /> RESERVATION <br /> 3 FARM 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 /> PHONE#WITH AREA CA <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH ARE CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMECARE OF ADDRESS INFORMATION <br /> q <br /> MAILING OR STREET ADDRESS ✓ box to Indicate 0 INDIVIDUAL 7] LOCAL-AGENCY 0 STATE-AGENCY <br /> /r— g 0 CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME~ ST <br /> VA— <br /> ATF, ZIP CODER PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 0, j2,n `! ur (]CORPORATION PARTNERSHIP 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 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 0 1 SELF-INSURED 2 GUARANTEE 0 INSURANCE n d SURETY BOND <br /> l 5 LETTEROFCR€DIT 6 EXEMPTION 0 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 WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1. II- III. <br /> THIS FORA+!HAS BEEN COMPLETED CINDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> W C7F] <br /> LOCATION <br /> CODE -OPTIONAL CENSUS TRACT# -OPTIONAL $UPVISOR-DISTRICT 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(5-91) FOR00 3A-5 <br />