Laserfiche WebLink
ebcua es°o <br /> STATE OF CALIFORNIA ^+ +. <br /> STATE WATER RESOURCES CONTROL BOARD _ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a�� va <br /> ,� n P.. oa <br /> /f cacao�•e <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY D 1 NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q S TEMPORARY SITE CLOSURE 0 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILSTY NAME. NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OF!"ONAL) <br /> CITY NAME STATE ZIP CODE faITE PH NE#WITH AREA COD <br /> Gds' CA 2l> �� <br /> TOINDIC TE D CORPORATON D INDIVIDUAL D PARTNERSHIP O LOCAL-AGENCY D COUNTY-AGENCY D STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 1 GAS STATION Q 2 DISTRIBUTOR / <br /> IF INDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.x(optional) <br /> O 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRS �PHHOORr E#WITH AREA C DIE__/ DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGH/HTS: NAME(LAST,FIRST) PHONE#WITH ALREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> l' w15611� <br /> MAILING OR STREET ADDRESS �1 ✓ boa bindbate 0INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION = PARTNERSHIP COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAM � STATE. ZIP CODE �N4 WITH AREA CODE,, <br /> III. TANK OWNER INFORMATION- (MUST BE COMPLETED) J <br /> NAAtEOF-OWNER !„ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRESSSY ,, boa blMbw D INDIVIDUAL LOCAL-AGENCY D STATE-AGENCY <br /> �G (�,J- { O CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY ;Ei� S`TiATE ZIP COD � ` HONE JITH AREA CODE3 <br /> 2 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER/-CCall(916)739-2582 ittqquesfions arise. J\ <br /> TY(TK) HQ F4-[-4]-� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or IIS gbecked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.AH.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUK­._Y# JURISDICTION# FACILITY# <br /> LOCATION <br /> m CODE -OIONA C2ENSU <br /> Z T•RACT# -OPTIONAL PVISOR-DISTRICT CODE OPTIONAL <br /> 8D 2v <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OFSRE IN ON ONLY. <br /> FORMA(e-90) <br /> FORM3A,R2 <br />