Laserfiche WebLink
°.... <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD � <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> onYn <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION J PERMANENTLY CL2LEGSITE <br /> ONE ITEM (_.; 2 INTERIM PERMIT _ A AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DOA OR;;CI 1r AME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> a ?- CA D <br /> ✓ BOX <br /> TO INDICATE E-1 CORPORATION DIVIDUAL [_1 PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY O STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS F__j t GAS STATION = 2 DISTRIBUTORq SERVATDION #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> O 3 FARM O A PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE A WITH AREA C07-7 YS: NAME(LAST,FIRST) P.�.r WITH AREA MDF <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITH AF15A CODF <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM <br /> /�/ CARE OF AODRHSS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boabintlkab INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 000RPORATION E=lPARTNERSHIP COUNTY-AGENCY 0 FEDERAL AGENCY <br /> CI NA ESTATE ZIP PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM OF O NER CARE OF ADDRESS INFORMATION <br /> MAILING CA STREET ADDRESS-�',�• ✓ WX NiMkaN INDIVIDUAL O LOCAL AGENCY (] STATE AGENCY <br /> CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> AME' C � STATE^ ZIP CODEPHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HO 144�-EL]== <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ w biibkate 1 SELF-INSURED U 2 GUARANTEE L_] 3 INSURANCE 0 a SURETY SONO <br /> 5 LETTEROFCREDIT Q 6 EXEMPTION = 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.= II.ly III.= <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&SIGNATURE) APPLICANPS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY <br /> ^ I - - - 2 0O <br /> LOCATION CODE OPTIONAL CENSUS TRACT -OPTIONAL ''SUPVISOR-DISTRICT CODE -OPTIONAL <br /> o?1y-4.� 3Zo <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(12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0033Aflfi <br />