Laserfiche WebLink
�•C p<zouAc"" <br /> STATE OF CALIFORNIA <br /> S I STATE WATER RESOURCES CONTROL BOARDtj t� o <br /> 2V) UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> t� <br /> COMPLETE THIS FORM FOR EAC CILITY/SITE <br /> MARK ONLY ❑ NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> /h/G G l0 2 <br /> ADDRESS ., NEAREST CROSS STREET PARCEL A(OPTIONAIU) <br /> ITY <br /> < /7 a Q. CC S <br /> CNAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> c C <br /> ✓ eox A <br /> TO INDICATE O CORPORATION 0 INDIVIDUAL E-1 PARTNERSHIP 0 LOCAL-AGENCY O COUNTY AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTORRESERVATION <br /> ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> ❑ 3 FARM E:7] 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) „ PHONE Al WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> G <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME _�,/Gy.(� .- CARE OF ADDRESS INFORMATION <br /> pe <br /> MAILING OA STRE/�/E5 �6 ✓ ypablMiple <br /> O INDIVIDUAL Q LOCAL.AGENCY Q STATE AGENCY <br /> _ 77U 0L < Aey lD CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> S G <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS- ✓ box bindbate INDIVIDUAL O LOCAL-AGENCY (]STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP = COUNrY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE%WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4—[4-]- <br /> V. <br /> s -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ------------- <br /> ✓ Nx loindicale I SELF INSURED 2 GUARANTEE 0 3 INSURANCE <br /> O 4 SURETY BOND <br /> L-1 6 LETTER OF CREDIT 6 EXEMPTION 71 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.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWOAV/VEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# �FAC�ILITY# <br /> 3 L? � /Mq�l6lli�L! <br /> LOCATION CODE OP - <br /> l <br /> TION iCENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> v 3 " ca <br /> THIS FORM MU T BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATION <br /> • FOR6673AR6 <br />