Laserfiche WebLink
a <br /> STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM ACOMPLETE THIS FORM FOR EACH F /SITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION_& - MUST BE COMPLETED) <br /> DBA ORF AME NAME OF OPERATOR <br /> rIca'Lk / Laurc ., <br /> ADDRESS NEAREST CROSS STR PMCEL#(OPTIONAU <br /> S• Gn ../ a cern �- <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> c CA SZo/ .2v BOX <br /> TO INDICATE CORPORATION I] INDIVIDUAL 0 PARTNERSHIP (]LOCAL-AGENCY ] COUNTY-AGENCY I] STATE AGENCY FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#rdpi=a/) <br /> RESERVATION I , <br /> 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS y <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME41AST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Z� Prmu� •S /3 - 73/- 3/3 <br /> IGHT MME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE <br /> It. PRO -0 ER INFORMATION- ST BE LETED <br /> CMAILING <br /> 7 _ CARE OF ADDRESS INFORMATION <br /> r» n LO 1 <br /> OR ET ADDRESS p / ✓ box bind'w I] INDIVIDUAL ] LOCAL-AGENCY I] STATE-AGENCY <br /> 7 CORPORATION (] PARUIERSHIP (] COUNTY#GENCY 0 FEDERAL-AGENCY <br /> ME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Co 5 1� 9'00 o 1,913-73 -3/3 2— <br /> Ill. TANK OWNER I MATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> S'Ir.T r+•e atS - _ - wn T n n A� S{,-vicel' <br /> MAILING OR STREET ADDRESS �/ppM bhpkale <br /> (] INDIVIDUAL = LOCAL-AGENCY STATE-AGENCY <br /> - CORPORATION l] PARTNERSHIP ] COUNTYAGENCY ] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ F4-T4]- <br /> V. <br /> 4 -V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checke <br /> CHECK ONE BOX INDICATING 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 /> APP LICANTS NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATIONCODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-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 /> FORM A(9-90) FOR0033A RR22 <br />