Laserfiche WebLink
a wtfi <br /> STATE OF CAUPonNIA '�L `os <br /> STATE WATER RESOURCES CONTROL BOARD �,-+`� '� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM Ar'/ ` `� "°� <br /> ry: . <br /> COMPLETE THIS FORM FOR EACH FACILITYISrTE �•`'"°""�� <br /> MARK ONLY Q NEW PERMIT ] RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 P f MANENTLY CL/ SED SITE <br /> ONE REM 2 INTERIM PERMIT Q A AMENDED PERMIT S TEMPORARY SITE CLOSURE r / <br /> fSsU� Seif <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> O8AqILFACILITYNAtAE NAMEOFOPERATOR <br /> A00 *5 /I /1 /^ v� STRE PMCELiIOPfgNAU <br /> CITY NANAA / 1J(/t STATEL Jr�G D D SITE PHONE t WITH AREA COCE <br /> G�tin CA <br /> v BOX <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL L; PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERALAGENCY <br /> OISTWCTS <br /> TYPE OF BUSINESS O 1 GAS STATION a 2 DISTRIBUTOR QJ IF INDIAN s OF TANKS AT SITE E.P.A. L D.'(npioinQ <br /> RESERVATION <br /> C ] FARM Q 6 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> JAYS: NAME(UST,FIRST) PHONE/WITH AREA CODEDAYS: NAME(LAST.FIRST) PHONE s WITH AREA CODE <br /> NIGHTS: ,NAME(LAST,FIRST) PHONE•WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE t WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ACOR-ESS INFORMATION <br /> .NAILING OR STREETi ADDRESS J by avginu Q INDIVIDUAL <br /> LJ LOCA4AGENLY IQ STATE.AGOICY <br /> Qi CORPORATION = PARTNERSHIP iQ COUNTY-AGENCY Q FFDERAL-AGENCY <br /> CITY NAME STATE LP CODE I PHONE A WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> I NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS IQ INDIVIDUAL <br /> Q LOCAL-AGENCY (_,;� STATE-AGENCY <br /> Q CORPORATION = PARTNERSHIP Q COUNTYAGENCY Q FPOERALAGENCY <br /> CITY NAME STATE i 21P CODE PHONE A 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 -� <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. II.J 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 B SIGNATURE) APPLICANTS TITLE DATE MONTWOAYNEAR SS <br /> LOCAL AGENCY USE ONLY -b �J <br /> COUNTY# ems_ JURISDICTION x FACILITY� <br /> F�7tq LE-X A( Z � I ITiTI1 <br /> LOCATION CODE -OPTIONAL I CENSUS TRACT a-OPT}Q� SUPVISOR-DISTRIICCJT CODE -OPTIONAL <br /> ( l 2 LUJ (/I <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(9 W) FORUfa]AA2 <br />