Laserfiche WebLink
IF <br /> STATE OF CALIFORNIA "� y o <br /> STATE WATER RESOURCES CONTROL BOARD W nom' Ae o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �-lir0""�� <br /> MARK ONLY O t NEW PERMIT E:] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q S TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> O <br /> ADDRESS NEAREST CROSS STREET PARCELA(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> CA 1 515-3 GG <br /> ✓ BoxI�pRpoMT N­ (]INDIVIDUAL 0 PARTNERSHIP 0 LOCALAGENCY 0 COuKrV-AGENCY' OSTATE-AGENCY' FEDERAL-AGENCY' <br /> gCATE DSTRICTS' <br /> 6 owner d UST Is a public agency,complete the following:name of Supervisor of&xIon,section,a office which operates the UST <br /> TYPE OF BUSINESS t GAS STATION Q 2 DISTRIBUTORRE/pyNDIAN 1#OF TANKS AT SITE E.P.A. I.D.a lstd�i <br /> Q TION <br /> 3 FARM Q 4 PROCESSOR THER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> 7] <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME / CARE OF ADDRESS INFORMATION <br /> i O/y <br /> MAILING OR STREET ADDRESS ✓Nor loll INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> X 0 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME /7G STATE ZIP CODE PHONE a WITH AREA CODE <br /> �( 36.E <br /> III. TANK OWNER INFORMATION (MUST BE COMPLETED) <br /> NAMEOFOWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box blMkst, INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION PARTNERSHIP 0 COUNTY AGENCY D FEDERALAGEMY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ F4-F4--] <br /> V. <br /> 4- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓�s bNdkab O t SOURNSURED 0 2 GUARANTEE O 3 INSURANCE 0 4 SURETY BOND <br /> D 5 LETTER OF CREDIT O 6 EXEMPTION �THER <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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II, III.0 <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(PRINTEDB SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ® 17-1311 ! <br /> LOCATION CODE -OPTIONALCENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL k-)r_pY <br /> - <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM Al31931 FOIiWI3AAT <br />