Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 'e <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 'tl <br /> 1. NEW PERMIT F—] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE <br /> IIIf DP�tT# �� 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACIL,Y/S:1•E INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACILITY NAME NAMEOFOPERATOR <br /> ADDRESS / NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 7 BOA E . CVO�fc S')r. �" �/fi',G/,� <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓BOX D CORPORATION [:1 INDIVIDUAL O PARTNERSHIP 171 LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> I owner d UST a a public agency,mmp6ts the following:name of supeN6or of 0Nisbn.Wen or oncew idi Womles Me UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR RE EIRVATION It OF TANKS AT SITE E.P.A. I.D.p(optional) <br /> Q 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS J t�OG (90/g�c pia" <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST, IRS HONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> I. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREEIT ADDRESS c ✓ boabuMcala 1NDMDUAL I�LOCAL-AGENCY INSTATE-AGENCY <br /> os G4�E' S O CORPORATION/�[::] PARTNERSHIP O COUNTY-AGENCY E__1 FEDERAL-AGENCY <br /> CITVjIAM/7/ STATE ZIP CODE HONE# ITHAREACODE <br /> !4i''LL7> 09 902 v;9 Zia 3,W- 6&� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OFOWNER <br /> /A y V■?� ,a 2 CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS /• �/ ✓ bMro Mute [__1 INDIVIDUAL O LOCAL-AGENCY E::] STATE-AGENCY <br /> OIvn - �� �-i CD CORPORATION O PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATEZIP CODE PHONE#WITH AREA CODE <br /> G C4 yz�r� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4-]-I_ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boa to Micale 1 SELF-INSURED 0 2 GUARANTEE 11 3 INSURANCE O 4 SURETY BOND O 5 LETTEROFCREDIr =6 EXEMPTION O 7 STATE FUND <br /> Q 9 STATE FUND&CHIEF FINANCIALOFFICER LETTFA O9 STATE RIND&CERTIFICATE OF DEPOSIT = 10 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 It is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[:] II.O 111.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY <br /> � FT71 I I I � s <br /> LOCAATIQNCODE -OPTIONAL CEy TTFOT# -OPTIONAL SyPVJ^pOO•R'-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 /> FORMA(6-95) OWNER MUST FILE THIS FORSH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRCf STORAGE TANK REGULATIONS <br />