Laserfiche WebLink
• STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 3"� v o <br /> . . o <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY ❑ I NEW PERMIT Ej 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ONE ITEM 7 PERMANENTLY CL ED SITE <br /> 2 INTERIM PEgM1T O d AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> P NAME OF OPERATOR <br /> 3 <br /> NEAREST CROSS STREET PARCEL#(OPTIONAL)�•. S s <br /> CIN NAME <br /> / STATE ZIP CODE SI PHO E x WITH AgEA CODE <br /> ✓ eox <br /> CA <br /> TO INDICATE CORPORATION I1 INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY — <br /> DISTRICTS COUNTY STATE-AGENCY <br /> TYPE OF BUSINESS [] FEDERAL-AGENCY <br /> 0 1 GAS STATION IISTRIBUTOR - ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(.Flim., <br /> O ESERVATION <br /> 3 FARM O 4 PROCESSOR O 5 OTHER OOR TRUST LANDS / <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> DAYS: NAME EMERGENCY CONTACT PERSON SECONDARY <br /> (LAST,FIP,RT) HONE#WITH AREA CODE (SECONDARY) optional <br /> NIGH /N AME L,//C dMS IT DAYS: NAME(LAST,FIRST) <br /> TS: N (LAST,F'RSn NE WITH AREA CODE <br /> NIGHTS: NAME ILAST.FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME <br /> / CARE OF ADDRESS INFOgMAT10N <br /> vSr /u-S L)n4'Att <br /> MAILING ORS EET ADORE S <br /> ✓ CO PbD C INDIVIDUAL LOCAL AGENCY <br /> ST STATE-AGENCY <br /> CITY NAME e COgPoRATION PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL <br /> ii �" ST ZIP CCODEc PHONE#WITH AREA CODE <br /> �V b /� �.k c• ✓4D S0 / — — d <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> CARE OF ADDRESS INFORMATION <br /> MAILING Oq STREET ADDRESS <br /> ✓ box biMkale 0 INDIVIDUAL 0 LOCAL-AGENCY <br /> 0 CORPORATION PARTNERSHIP l� FEDERSTATE AL-AGENCY CIN NAME �COUNTY-AGENCY � FEDEML-AGENCY <br /> STATE ZCODE PHONE#WITH AREA CODE <br /> IV. <br /> TY(TK) HO 4�-BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY � <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicale [ 1 SELF-INSURED 0 2 GUARANTEE <br /> 5 LETTEROFCREDITL�6 EXEMPTION Cf 99 OTHER <br /> O 3 INSURANCE 0 4 SURETYBOND <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless b or II is the d. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> I. II. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TR E AND CORRECT <br /> APPLICANTS NAME(PRINTED A SIGNATURE) <br /> APPLICANTS TITLE DATE MONTH/DAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# -So <br /> ��� FACILITY# <br /> LOCATION CODE OPTION —I__�= / <br /> AL (CENSUS TgACT# -OPTIONAL SUPVISOR-DISTRICTCODE - <br /> �l3 b OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS S IS A CHANGE OF S TE INFORMATION ONLY. <br /> FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 3�g1gy FOR0033AAs <br />