Laserfiche WebLink
• " V <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD id •" _cY <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACHILRYISITE °��,.°erg• <br /> MARK ONLY F-11 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLQSi <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA AOCILITY NAME n U C, NAME FOPERATOR <br /> ADDRESS C '-4 rl a RAV zjo <br /> S E7 NEAREST CROSS STREET PMCELp(OPTIONAL) <br /> (t f/Vt <br /> CITU NAME STATE ZIPQODE� k(AD <br /> E#WITH AREA CODE <br /> ✓ BOX CA Y !!//OOT//WO <br /> TO INDICATE X.CORPORATION Q INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY <br /> DISTRICTS O STATE-AGENCY FEDERAL-AGENCY <br /> TYPE OF BUSINES 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.0(opfionap <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•Optional <br /> DAYS: NAME(LAST,FIRST( PHONE xLWITHZRE6 CODE_ DAYS:NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITHAREA CODE NIGHTS: NAME(LAST,FIRST) <br /> WITH AREA COOP <br /> Il. PROPERTY OWNER INFOR TION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ hox bintlkate L_j INDIVIDUAL O LOCAL-AGENCY 11 STATE-AGENCY <br /> CORPORATION O PARTNERSHIP = COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST B OMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box blMkaU O INDIVIDUAL LOCAL-AGENCY 0STATEAGENCY <br /> CORPORATION I� PARTNERSHIP EDCOUNTY-AGENCYt� FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOU NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECO LETED)—IDENTIFY THE METHOD(S) USED <br /> %/ box It,Indicate 1 SELF-INSURED 2 GU NTEE = 3 INSURANCE <br /> d SURETY BOND <br /> O 5 LETTEROFCREDn b EXEMP ON 0 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: I.❑ II.❑ It. <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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY / <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE =OPTIONAL CENSUS TR CT -OPTIONAL SUPVISOR-DISTRICT LADE -OPTIONAL <br /> r o71 <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 /> -/]FFO/R�M A(5I-9�1) 7I (` [� /-� -y'/% <br /> ,D /If� / I _Uta, a.L� � /�� l �� �� I C.� FOR0033A5 <br />