Laserfiche WebLink
SEPq <br /> E STATE OF CALIFORNIA <br /> STATE=TER RESOURCES CONTROL BOARD <br /> wa <br /> U-NDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACUtCILrrYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED S <br /> ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> L FACILITY/SITE INFORMATION& ADDRESS- (MUST BE COMPLETED) <br /> DRA OR FACILITY NAME <br /> NAME r� TEFOPERATIIR <br /> PARCEL#IOPnONALI <br /> ADDRESS OSS STREET'1(v4-1 AL1F VJVAViA a-? — — 4CITY NAME ZIP CODE SITE PHONE#WITH AREA CODE <br /> 209-`t52 45l <br /> BOX RPORATIdN INDIVIDUAL [] PARTNERSHIP 0 LOCAL•AGENCY Q COUNTY-AGENCY [� STATE-AGENCY (] FEDERAL-AGENCY <br /> TOINDICATE DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ./ IF INDIAN #OFT NKS A7 ITE E.P.A. I.D.#(optional) <br /> C� 0 RESERVATION <br /> 3 FARM 0 4 PROCESSOR = 5 OTHER OR 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) <br /> AIIIATt 9l - N _1609M <br /> r___ A PH(3NE 11Y <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> It PR TY NER IN RMATIO MUST B OMPLET <br /> F C E OF AD R SS INFO MA ION <br /> M ✓<IN S E RESS INDI IDUAL L L-AG NCY STATE-AGENCY <br /> PAR ERS IP C NTY A ENCY 71 EDE AGENCY <br /> HONE# 4TH REA CODE <br /> CI A <br /> III. TANK OW R INFORMATION-(M E COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 5F 01 L_ GO fkm D&SAmm-7 <br /> MAILING OR STREET ADDRESS V box is Indicate INDIVIDUAL 0 LOCAL-AGENCY [] STATE-AGENCY <br /> 25&8CORPORATION [] PARTNERSHIP [] CCUNry-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME I STATE ZIP CODE PHONE#WITH AREA CODE <br /> CA CIC-161-0 90.0'fo3 -&'-t t9 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 V41- p q <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE M OD(S) USED <br /> 1 SELF-INSURED D 2 GUARANTEE 3 INSURANCE 0 4 SURETYRDND <br /> box 10 indicate <br /> 7—] 5 LETTER OF CREDIT Q 6 EXEMPTION 049 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked, <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BA-LING: I.D II.[_—] III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) CHEyScti APPLICANTS TITLE DATE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# 0&71,p JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICTCODE -OPTIONAL <br /> 0 Z3. 84 1 3 <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, Cr <br /> FORM A(5-91) ( FCR0033A5 <br />