Laserfiche WebLink
• • `a ue <br /> STATE OF CALIFORNIA ^ c+o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A a <br /> COMPLETE THIS FORM FOR EACH FACILNYISITE `"'•°^"� <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE S3 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME \ NAME OF OPERATOR <br /> Y oo <br /> ADDRESS n /J NEAREST CROSS STREET PARCEL#(OPTKINAU <br /> Gc✓ � ll`/CAU <br /> CITYNAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> TO INDICATE 0 CORPORATION 0 INDIVIDUAL �ERSHIP O LOCAL-AGENCY O COUNTYAGENCY' O STATE-AGENCY' O FEDERAL-AGEWY' <br /> DISTRICTS' <br /> •If owner of UST Is a public agency,conplete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR = RESERVATDIAN #OFTANKSATSITE E.P.A. I.D.#rophnaq <br /> hl <br /> 3 FARM ❑ 4 PROCESSOR = S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optimal <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 s WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME ./� CARE OF ADDRESS INFORMATION <br /> J n Jl o <br /> MAILING OR STREET ADDRESS ✓ boablMkaN D INDIVIDUAL O LOCAL-AGENCY DSTATE-AGENCY <br /> 12-1 4S AlIle J -Ls O CORPORATION =PARTNERSHIP O COUNTYAGENCY Q FEDERAL-AGENCY <br /> CITY NAMEy� STATE ZIP CODE PHONE#WITH AREA CODE <br /> oX ?5 ZYz <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓b]abindkaw = INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP Q COUNTYAGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 it questions arise. <br /> TY(TK) HQ F4-T4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boa bindkab 0 1 SELF-INSURED E]2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND <br /> c O 5 LETTEROFCREDIT O B EXEMPTION 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JrURISDICTION# FACILITY# <br /> F391LLQ J 17131117D <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 9UPVISOR-DISTRICT CODE -OPTIONAL 7%/f <br /> o u oat <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS/\Q`N, FORDISSM <br /> FORM A(393) • 0 ^ ` <br /> `y <br />