Laserfiche WebLink
0 <br />E <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EACH FACILTTYISITE <br />4A <br />I. FACILI I YIJI I C NYrvirtivieeI Ivry a nvvnw.+- p•...-• • -- <br />❑ I <br />NEW PERMIT <br />❑ 3 <br />RENEWAL PERMIT <br />❑ 5 <br />CHANGE OF INFORMATION <br />❑ 7 PERMANENTLY CLOSED SITE <br />MARK ONLY <br />ONE REM <br />❑ 2 <br />INTERIM PERMIT <br />❑ d <br />AMENDED PERMIT <br />❑ 6 <br />TEMPORARY SITE CLOSURE <br />?Z2 2 <br />I. FACILI I YIJI I C NYrvirtivieeI Ivry a nvvnw.+- p•...-• • -- <br />- ---- ---- . <br />NAME OF OPERATOR <br />JURISDICTION It <br />DBA OR FACILITY NAME <br />v 64S <br />NEAREST CROSS STREET <br />PARCEL #(OPPONAL) <br />ADDRESS <br />CENSUS TRACTN -OPTIONAL <br />SUPVISOR- DISTRICT CODE -OPTIONAL <br />STATE LP CODE <br />SITE PH E # WITH AREA CODE <br />CITU NAME <br />CA lZ <br />Zt, n 1 3 - - <br />rTT: INFnRMATION ONLY <br />✓ BOX CORPORATION (] INDIVIDUAL O PARTNERSHIP <br />0 COUNTY -AGENCY' <br />STATE -AGENCY' O FEDERAL -AG Cy' <br />DISTRICTS <br />TO INDICATE <br />' # UST's a DUEk egenry, w�lele #rololbwng rame d stgervkord Qrvsion, section or <br />o#re w#iCi oDeon the UST <br />ownerof <br />NOF TANKS AT SITE E.P.A. I. D. M (optional) <br />❑ <br />TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR <br />RESERVATIION <br />O 3 FARM ❑ d PROCESSOR Q <br />5 OTHER OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) �1Y1C^��^� ��•"^--'-- ----- ' <br />)AYS: NAME (LAST, FyIRS,T)l PHONE N WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />LlPHONE # WITH AREA CODE <br />JIGHTS: NAME (LAST, FIRST) PHONE a WITH AREA CODE NIGHTS: NAME (LAST, FIRST) <br />rsmnnu annM _ /1111 ICT FTP 1711MW1 H t InUI <br />CARE OF ADDRESS INFORMATION <br />NAME /I- <br />�StiL Gam' % ✓ tooXto#eNTale <br />G ALy INDIVIDUAL O LOCAL -AGENCY = STATE -AGENCY <br />MAILING OR STREET ADDRESS � CORPORATION PARTNERSHIP = COUNTY -AGENCY = FEDERAL -AGENCY <br />27,01 C, <br />!� STATE � ZIP CODE P ONE pN WITH AREA CODE <br />CITY NAME 1 l - 04 � �� b-/ .LJ <br />III. TANK OWNER INFORMA I IUN • (mua 1 Co 1,we lr Lc i c. ) <br />STREET <br />NAME <br />OF ADDRESS <br />✓ tomMkoet- NDNIDUAL O LOCAL -AGENCY STATE -AGENCY <br />Q CORPORATION PARTNERSHIP = COUNTY -AGENCY Q FEDERAL -AGENCY <br />-1— >io cnnF PHONE # WITH AREA CODE <br />----------- e Annn, kiT kit 111RPo - r.nn fot Rl 39mmg if OUestions arise. <br />I V. CUHHU Ur CVuAucnrwn <br />TY (TK) HO 4 4 - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY -(MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to#tli(NIte 1 SELF INSURED O 2 GUARANTEE Q 3INSURAN'CE O N SURETY BOND O 5 LETTER OF CREDIT = 6 EXEMPTION I= 7 STATE RINO <br />= a STATE FUND 8 CHIEF FINANCIAL OFFICER LETTER = B STATE FUND 6 CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT. MECHANISM 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 />;HECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br />❑ n. ❑ nI. <br />uAr rrru rnAAPIr Pn UNDER PENALTY OFPERJURY, AND TO THE SESTOF MYKNOWLEDGE, IS TRUEAND CORRECT <br />TANK OWNER'S TITLE DATE MONTHiDAYNEAR <br />ANK OWNER'S NAME (PRINTED 8 SIGNATURE) <br />LVI.NL HUCIYIAI uJr-vn�t <br />COUNTY # <br />JURISDICTION It <br />FACILITY # <br />LOCATION CODE -OPTIONAL <br />CENSUS TRACTN -OPTIONAL <br />SUPVISOR- DISTRICT CODE -OPTIONAL <br />s� J <br />rTT: INFnRMATION ONLY <br />THIS FORM MUST BE ACCOMPANIED BY AT LE IT) UK MUHt YCHMI I AYYLIb.'.V11 - r v, .. •ry .- ----- -- ," <br />OWNER MUST FILE THIS FORM HE LOCAL AGENCY IMPLEMENTING THE UNOERGROGROUN�flAGE GE TANK REGULATIONS <br />FORM A (695) <br />