Laserfiche WebLink
P,y50VRGP8 C? <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3 ' <br /> !� <br /> UNDERGROUND STORAGE TALK PERMIT APPLICATION - FORM A, <br /> ��-- COMPLET€THIS FORM FOR EACH FACII-ITYISITE <br /> MARK ONLY L J 1 NEW PERMIT F-] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY GLCS,�C SITE f <br /> ONE ITEM 2 INTERIM PERMIT —J 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE f <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DRA FILfiITY NAME NAM OF OPERATOR <br /> eaten �nz��es <br /> ADD-R�ESSS ,r� /� NEARES RCSSSTREEr PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP C E SI E PHO E#WI <br /> Th ARD,CODE I <br /> ✓ BOX CORPORATION INDIVIDUAL (7 PARTNERSHIP ] LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGLN;Y Cl FEDERAL-AGENCY <br /> TO INDICATE DISTRICTS <br /> TYPE OF BUSINESS ./ IF INDIAN #OF T AT SITE E.P.A. I.D.#(oplioral) <br /> 1 GAS STATION 2 DISTRIBUTOR RESERVATION ` <br /> 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS �! <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (S€CONDAPY)-optional <br /> D S: NAME(LA T,FIRST) PHONE#WITH AREA CODE DAY NAME{LAST,FIRST) <br /> o1'tZ� �� ,na .ZC.1� �,5.a_ t�ls/S P, 's' Z_ !.S lea 1 a7 NELH AWEA C,DQE_- <br /> NIGHTS: AMF(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: A E;LAST,FIRST) <br /> r ,�, e,Me� ,� <br /> et�►1e �,.Lc �---27 --357 `7 -,0 <br /> If, PROPERTY Q ER INFORMATION- MUST BE COMPLETED <br /> NAME C RE OF ADDRE"FORMATION <br /> +C MAILIN OR STREET WOPESS / -. bop�indkate [] INDIVIDUAL 0 LOCAL-AGENCYI� STATE-AGENCY i <br /> 01 / o �J CORPORATION [] PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY= I <br /> CI NAME c� STA ZIP CODE6 �NE#W'Th ARTA CODE <br /> —<3737 <br /> III. TANK OWNER INFORMATIOr-(MUST BE COMPLETED) <br /> NAME O OWNER ;EC OF ADDRESS II RMATION <br /> Lf /t—V J' al�l1%MAILING OR STREE DRESS ox W indicate CINDIVIDUAL LOCAL-AGENCY C STATE-AGENCY <br /> ORPORATION (� PARTNERSHIP COUNTY-AGENCY FEDERAL-ACEiJCtNAME E ZIP C �Zo�XM <br /> PHONE W17 AREA CODE —� <br /> Qh a 63/—x733 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ K]- Q '7 ,0 6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHODS) USED <br /> ✓ boll Io Indicate 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 0 4 SURETY3OND I <br /> 5 LETTEP OF CREDIT C 6 EXLNIPTION 99 OTHER �y <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal ndficat on and b',lling will be sent to the tank owner unless box i or li is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORA?HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE >PPLICAN78 TITLE DF TE MONTH/DAYlYEAR <br /> I <br /> *I<< 6e�^A wneJ�—a -- <br /> LOCAL AGENCY USE ONLY __ <br /> COUNTY# JURISDICTION# FACILITY# ` <br /> TN / - _ l LLLL7- 1 ,1� - <br /> LOCATION C -OPTIONAL CENSUS TRACT# -OP ON SUPVISOR-DISTRICT O -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 0 33A-5 <br /> FORM A(5-91) <br />