Laserfiche WebLink
• oua es <br /> STATE OF CALIFORNIA eo <br /> STATE WATER RESOURCES CONTROL BOARD to <br /> UND ROUND STORAGE TANK PERMIT APPLICATION- FORM A W �; <br /> COMPLETE THIS FORM FOR EACH YISITE <br /> MARK ONLY ❑ 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE F <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBAOR FACILITY NAME A _ NAMEOFOPERATOR <br /> Tu0 .1 ryn yG.��v 7x <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> . Sc <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> TOINDIIC TE CORPORATION INDIVIDUAL =PARTNERSHIP (] LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TANKS AT SITE A. I.D.#(opl/mal) <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION <br /> ❑ ❑ ❑ OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> S'C e er r✓ /o f 8L17-3& L(o 0 f 78.0 <br /> NIGHTS: NAME(LAST,FIRS PHON #WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> S G AY1,Q <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> W617 <br /> MAILING OR STREETADDRESS ✓ Indicate INDIVIDUAL f� LOCALAGENCV (�STATE-AGENCY <br /> . f� .j CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAT L� b STATE ZIP CODEPHON #WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> RS <br /> MAILING OR STREET ADDRESS ✓ box bIndicate INDIVIDUAL ED LOCAL.AGENCV <br /> (�CORPORATION Q PARTNERSHIPI I7FEDERAGENCV <br /> 0 COUNIY-AG WITH (- FEDERAL-AGENCY <br /> CITY NAME STATE 21P CODE PHONES WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 44 - D 3 r1 <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is the <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ it. III.❑ <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 B SIGNATURE) APPLICANT'S TITLE DATE MONTWDAYNEAI <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION* FACILITY# �NOU593 <br /> LOCATIONCOD—TONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DIST TCODE -OPTIONAL <br /> 3actA X33 <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 R2 <br />