Laserfiche WebLink
• • soVM1 [ <br /> STATE OF CALIFORNIA A�� ` <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A 'n� ': <br /> z, oN <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ q AMENDED PERMIT <br /> ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION III ADDRESS-(MUST BE COMPLETED) <br /> ORA OR FACILITY NP.ME <br /> i - NAMEOFOPERATOR <br /> ADDRESS <br /> NEAREST CROSS STREET PARCEL N(OPfIONAL) <br /> STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Baa% CA -702 ,�) <br /> TO INDICATE E]CORPORATION Q INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY 0 COUNTY AGENCY' Q STATE-AGENCY' <br /> -If inner o/UST Is a public agency,complete the following:name of Supenkor of CNbbn,,eclbnDIS RIOTff im whbh aper,,,,the UST FEDERAL AGENCY' <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR E5 ✓ IF INDIAN NOF TANKS AT SITE E.P.A. I.D.#(cpliana# <br /> ❑ 3 FARM ❑ q PROCESERV <br /> ESSOR ❑ 5 OTHER ORTRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> DAYS: NAME(LAST,FEMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> I P ONE# TH AREA IODE DAYS: NAME LAST,FIRS <br /> ,ei cjy l7 Sn PHONE If WITH AREA CODE <br /> NIGHTS: NAME ILAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> --------------- <br /> II. PROPERTY OWNER INFO R ATION• MUST BE COMPLETED <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> GGA /G o/ 6' ski�T <br /> MAILING OR STREET ADDRESS ✓ box birbbate <br /> C Q INDIVIDUAL LOCAbAGENCVSTATE <br /> vl�/ ��' J T-- CORPORATION 0 FEDERAL ADEN <br /> ENCY <br /> CITU NAME D PARTNERSHIP O COUNTY � FEDERAL <br /> Q'T STATE ZIP CODE PHONE N WITH AREA COPE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box binobau <br /> R!1 ,[ �.T— 0 INDIVIDUAL LOCAL 0 STATE AGENCY <br /> CITY NAME !�/ [�/ CORPORATION O PARTNERSHIP = COUNTYAGENCY = FEOEPALAGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CO E <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bindbau 1 SELF INSURED [7:12 GUARANTEE EA 3 INSURANCE <br /> 5 LEITEROFCREDIT E-36 EXEMPTION 1 SURETY BOND <br /> 99 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.❑ II. Ill.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED a SIGNED) OWNER'S TITLE <br /> DATE MONTWDAV/VFAq <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CGDE -OPTIONAL CENSUS TRACT# -OPTIONAL 3UPVISOR- <br /> � � DISTRICT CODE -OPTpAUL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PER APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3'93) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 0 <br /> 0 FOR5033A-R7 <br />