Laserfiche WebLink
<coue e <br /> STATE OF CALIFORNIA °O <br /> STATE WATER RESOURCES CONTROL BOARD 3y. <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A w�`� '"e <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °����°"�1� <br /> MARK ONLY 77 1 NEW PERMIT O 3 RENEWAL PERMIT Q 6 CHANGE OF INFORMATION EV7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE 5 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DR OR AGILITY AME O/ 4:7� NAMEOFOPERATOR <br /> A E 3 36— h v r) ile- �,J N RE TCR SS STREET PARCEL#(OPTIONAL) <br /> CITYN E STATE ZIP WPE SITE PHONE#WITH AREA CODE <br /> CA <br /> BOX <br /> TO INDICATE O CORPORATION 0 INDIVIDUAL l=PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY FEDER.ALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O t GAS STATION 0 2 DISTRIBUTORD <br /> RESERVATION <br /> IF INDDIAN <br /> OR #OF TANKS E.P.A. I.D.#(optimal) <br /> O 3 FARM Q 4 PROCESSOR Q S OTHER TRUST LANDS <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 /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b Indicate D INDIVIDUAL [71 LOCAL-AGENCY ED STATE-AGENCY <br /> CORPORATION O PARTNERSHIP D COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION- (MUST BE COMPLETED) <br /> NAME OF OWNEq CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS bolo Mbale D INDIVIDUAL LOCAL-AGENCY <br /> 0 STATE-AGENCY <br /> I�CORPORATION D PARTNERSHIP COUNTY-AGENCY E-1 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP 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 - U�� <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.O II.O III.O <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 MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY ��77 <br /> COUNTY# (gyp/ny _ JURISDICTION# FACILITY# <br /> 39UN CA 28 <br /> LOCATIONf -OPTIONAL CENSUS TRACTS -OPOONAL7 OR-DISTRICT CODE -OP NAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LLEEASTTT(((1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A("0) /& FG9 A-R2 <br />