Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD -�,� , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A >° n- <br /> J� COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY I NEW PERMIT � 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTL'I CLOSED SITE <br /> ONE rTEM 2 INTERIM PERMIT Q d AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAME OF OPERATOR <br /> DBA OR FACILITY NAME <br /> An O NS <br /> ^CO QAC (D�� J PARCEL 0(OPTIONAL) <br /> ADDRESS NEAREST CROSS STAEE7 <br /> 4*55 S(H e !\w 4q Fao tCave 1 � <br /> CITY NAME STATE ZIP CODE SITE PHONE I WITH AREA CODE <br /> om CA (2oC, <br /> ✓ BOX CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY ED COUNTY-AGENCY' O STATE.AGENCY' O FEDERAL.AGENCY' <br /> TO INDICATE DISTRICTS <br /> 'poxnerd USTea puE6:egenry.wrtgkle 9H bbwn¢re,nedsweA+eord Qmtlon.._WdrAexelCi9Pelela Ne UST <br /> TYPE OF BUSINESS 1 GAS STATION O 2 DISTRIBUTOR O RESERVATION <br /> F INDIAN °OF TANKS AT 517E E.P.A I.D.I(o0tronalJ <br /> 3 FARM Q A PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONyY WITH AREA CODE DAYS: NAME LAST.FIR T) PHONE WITH AREA CODE <br /> M 0. �JvT ( ib`1\448 -a 3� CrCo �n\rreT W,&SL �soo 2�2 (o3a° <br /> P ON ♦WITH AREA CODE NIGHTS: NAME(UST.FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(IAST,FIRST) <br /> ��y� •ay3� <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> �) \ , CARE OF ADDRESS INFORMATION <br /> NAME <br /> RQCU (r() cc, - Cf1 6 S <br /> MAILING OR STREET DRESS 1 ^ ✓ �10°�1a O INDMWAL O LOCAL-AGENCY OSTATE-AGENCY <br /> ( !Q ��I. �J3� CORPORATION Q PARTNERSHIP � COUNTY-AGENCY O FEDERAL-AGENCY <br /> CIN NAME (� � `��FF STATE ZIP CODE PHONE N NTH AREA CODE <br /> 1.kJ��S1 � C.q go�o2—1,o3g (-ILv� b"lo-S�u <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> \ ARE OF ADDRESS INFO R ATION <br /> NAME OF OWNER <br /> RCc� �rOC1J.°�s CO� EE}5 <br /> MAILING OR STREET A DRESS I� W, O0Z10^ . [= INDIVIDUALE__) LOCAL-AGENCY STATE-AGENCY <br /> Ue Q CORPORATION O PARTNERSHIP O CDUNTY-AGENCY FEDERAL.AGENCY <br /> CITY NAME ` ST E ZIP CODE PHONE THAREA CODE <br /> s, es�� r e, ozI -boa C� Lv7 hw —SL�O <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HO 44- - 6 d O S 0 lv <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Em to Mklle Pm I SELF-INSURED O 2 GUARANTEE O 3 NSURANCE O e SURETY BOND O 5 LETTEROFCREDT O 6 EXEMPTDN � T STATEFUND <br /> B STATE FUND 6 CHIEF FINANCIAL OFFICER LETTER O9STATE RIND&CERTIFICATE OF DEPOSIT O 19 LOCAL GOVT.MECHANISM = 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: I.O it,0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT T <br /> TANK OWN R'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MQNT AY/YEAR <br /> �tJv . CD �v�Q �YYI�N ' 31119� <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION N FACILITY a <br /> m <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 SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS F ITH THE LOCAL AGENCY IMPLEMENTING THE UNDERG D STORAGE TANK REGULATIONS <br /> FORMA(6-95) SQN V94C1vIK C0 � 'F'.o .t'uO4I 385 S -L)(.TLW CA. 45101-W,9 S <br />