Laserfiche WebLink
• noua es <br /> STATE OF CALIFORNIA 'n s <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EAC FACIUTYISITE <br /> MARK ONLY r NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT 0 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE 29 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS H& Pq <br /> NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> T <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AR DE <br /> M t� CA <br /> I/ BOX <br /> TOINDIC TE O CORPORATION INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O coUNrY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 t GAS STATION 0 2 DISTRIBUTORO -/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> RESERVATION <br /> O 3 FARM Q 4 PROCESSOR 0 5 OTHER ORTRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> W-DI <br /> MAILING OR STREET ADDRESS ✓ Wx to Wicate I1 INDIVIDUAL = LOCAL-AGENCY 0 STATE-AGENCY <br /> 2393-7- kt , HIAN Pq CORPORATION = PARTNERSHIP O COUNTY AGENCY E3 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE HONE WITH AREA CODE <br /> C - <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME a3NERLE <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box bintlkals Q INDIVIDUAL Q LOCAL-AGENCY 0 STATE-AGENCY <br /> 231 D CORPORATION ED PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATEZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 -E]=-] <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 ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[71', II.O H. <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) APPLICANTS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNT# dldR16BK:F16NM $W 5 FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-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 SRE INFORMATION ONLY. \ <br /> FORM A(9.91U FORM3A R2 <br /> \ C <br />