Laserfiche WebLink
1 <br /> 4� <br /> STATE OF CALIFORNIA .. <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> O 1 NEW PERMIT 3 RENEWAL PERMIT 6 CHANGE OF INFORMATK%N 7 PERMANENTLY CLOSED SITE <br /> MAflK GNLY A AMENDED PERMIT Q # TEMPORARY SITE CLOSURE S <br /> ONE REM � 2 INTERIM PERMIT 0 <br /> I. FACILITYISITE INFORMATIO7M7-(MUST BE COMPLETED) <br /> of OPERATOR <br /> DRAOR FACILITY NAME NEARESTCROSSSTREET PARCEL a(OPTIONAL) <br /> ADDgSS R <br /> STATE ZIP CODE SITE PHONE#WITH ARFA CODE <br /> CITY LOCA-AGENCY CWMY#GENCY' OSTATE-AGENCY' O FFDEPAL#GENCV' <br /> RPORATION O INDIVIDUAL 0 PARTNERSHIP 0 D6TRICTB' <br /> If oncy.coPpele the IWowlne:nanw of Supervlaor of dN4bn,a#clbn,or office which operates the UST <br /> ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(OP#anap <br /> TYPE OF BUSINESS 1GAS STATION Q 2DISTRIBUTOR RESERVATION <br /> 0 3 FARM Q a PROCESSOR Q S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY : NAME(LAST,FIRSTI ss�A PHONE#WITH AREA CODE <br /> DAYS: NAME(LAST,FIRST <br /> PHONE#WITH AREA CODE <br /> CQn - CY O l t <br /> 1 z- AREA NIGHTS: NAME(LIST,FIRST) PHONE#WITH AREA CODE <br /> PHON <br /> NIGHTS: NAME(LAST,FIRST) t <br /> IL <br /> If. PROPERTY OWNERINFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME <br /> .1 box bindicale I� INDIVIDUAL O LOCAL AGENCY L_] STATE-AGENCY <br /> MAILING OR STREET ADDRESS <br /> Q CORPORATION O PARTNERSHIP OCOUNTY-AGENCY = FEDERALAGEHICY <br /> STATE ZIP CODE PHONE a WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> E <br /> E OF OWNER ✓boabbdV00 I� INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> ING OR STREET ADDRESSQ CORPORATION �PARTNEASHIP =COUNTY-AGENCY FEDEMLAGESTATE ZIP CODE PHONE#WITH AREA CODE <br /> NAME <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HOF414--] <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> I SELFINSURFD f�2 GUARANTEE O J INSURANCE (]1 SURETY BOND <br /> boa bWkW5 LETTER OF CREDIT O S EXEMPTION O 9e OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> I.❑ IL= ill.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED A SIGNED) <br /> OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> JURISDICTION# �FACILITY <br /> # <br /> CI�O)U}iIN'TYII# m� <br /> CSUpy . <br /> TSI_—OJP—T--7LN-AI-L <br /> E01 OPTIONAL <br /> DENSUS TRACT &L9// - <br /> LOCATTHIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND <br /> ,(STORAGE <br /> ITANK <br /> REGULATIONS T <br /> FORM A(3N31 • f �0 )s / <br /> li�3r��fu <br />