Laserfiche WebLink
• aOVA <br /> STATE OF CALIFORNIA ^e <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> 01l InOXN,n <br /> i COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSUR f C� <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Estate of Louis DeLuca Dave Devine <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAO <br /> 14248 E . Peletier Road ac tone <br /> CITY NAME STATE ZIP DE SITE PHONE#WITH AREA CODE <br /> Acampo CA �LuI 209-727-5864 <br /> I/ Box <br /> TOINDIIC TE O CORPORATION X] INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY AGENCY O STATE AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RE/ IF INDIAN SERVATION #OF TANKS AT SITE I E.P.A. I.D.#/nplirn N f <br /> 3 FARM 0 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS 3 ®® 3 V/ - <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODEDAYS: NAME(LAST,FIRST) <br /> Devine Dave 209-727-5864 <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> Devine , Dave 209-369-0059 PRONE#WITH AREA COQP <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Estate of Louis DeLuca <br /> MAILING OR STREET ADDRESS ✓ boxbindicile ® INDIVIDUAL E�j LOCAL-AGENCY O STATE-AGENCY <br /> P . O . Box 316 CORPORATION 0 PARTNERSHIP 0 COUNrY-AGENCY FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Lockford CA 1 95237 09-727-5864 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Estate of Louis DeLuca <br /> MAILING OR STREET ADDRESS ✓ box0 Wicalx, INDIVIDUAL <br /> E-1 LOCAL-AGENCY Q STATE-AGENCY <br /> P . O . Box 316 CORPORATION O PARTNERSHIP COUNTY AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE <br /> #WITH AREA CODE <br /> Lockford CA 95237 209-727-5864 <br /> IV, BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4-T4]- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box b iMkate 0 1 SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT 6 EXEMPTION 99 OTHER <br /> VI. LEGAL OTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box Iorllischecked. <br /> CHECK ONE BOX IN ICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> '1'1 APP CANT'S NAM (PRINTE08 SIGNATU APPLICANTS TITLE DATE MONTH/OAYNEAR <br /> �'OS E j-�VfMd , f+� <br /> O — <br /> 11/20/92 <br /> LO AL AGENCY USE ONLY tl <br /> COUNTY# JURISDICTION# FACI <br /> 3 P161—LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 7L�L3 7SZ '7�� <br /> T 7 S FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) # A/ FOR0033A <br />