Laserfiche WebLink
STATE OFCALIFORMA <br /> STATE WATER RESOURCES CONTROL BOARD + ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A <br /> C <br /> MPLETE THIS FORM FOR EACH FACILITY/SITE °•r„e,,,.•� <br /> MARK ONLY 1 NEW PERMIT IY3 RENEWAL PERMI ibF-INFO TK]N Q 7 PERMANENTLY CLOSED SITE <br /> ONE REM O 2 INTERIM PERMIT L] 4 AMENDED PERMIT 0 S TEMPORARY SITE CLOSURE <br /> I. FACIUTY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DSA ORRACILLTYNAME-40Q NAqq ���yEE/El Dorado Unocal <br /> A'fM N. a Dorado NE'FlaKll RWTE96do PARCEL#(OPTIONAL) <br /> C� STATE ZJp�CyDE- $ITS PHON a W�19REA CODE <br /> ✓ BOX ,SLA ��� 30. <br /> TO INDICATE LJ CORPORATION 11 INDIVIDUAL O PARTNERSHIP p LOCAL-AGENCY ED COUNTYAGENCY' <br /> DISTRICTS• OSTATE-AGENCY' FFdERALA(9ENCV• <br /> R owner d UST Is a public agency,complete the following:name It SuPervkor of olv4bn,cectbn.W 011106 Which eperteec the UST <br /> TYPEOFBUSINESS f GASSTATION F 2 DISTRIBUTOR ✓ IF <br /> RINDIAN 4O TANKS AT SITE E.P.0.CAI opficnag <br /> Q 3 FARM Q 4 PROCESSOR 0 6 OTHER O RESERVATION 3 <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonal <br /> ryIGH <br /> Doraclo <br /> USI PHONE i.SII7J-1ABEACft DAYS: NAME(LAST.FIRST) PHONE It WITH AREA CODE <br /> JIFnTMt.varur //CfC1borado Unocal PHONE LIRI�/4d4ill lM NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAMESusan Sandelman Trustee, CARE OF ADDRESS INFORMATION <br /> MAIL STR_Fes__ __DBE$G,�1DD ✓ybubi�� � INDIVIDUAL 0 LOCAL-AGENCY ED STATE-AGENCY <br /> 11 TIyWWfI ECG. EAORpopmoN O PARTNERSHIP cauti AGENCY ED FEDEMLAGENCV <br /> CITYjNWft Plaine STIL¢.- ZIP COD67m7 PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) IVY <br /> 8"141 Company, LLC kAL I” <br /> D €`r�NA4R�14�'SitR�IbTnce <br /> M ING OR STR T DRESS ,,..✓yyb�or birdkme INDIVIDUAL O LOCAL-AGENCY (l STATE-AGENCY <br /> P-0. 60 5 3 czOIRPOMTION O PARTNERSHIP Q COUWY AGENCY 0 FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE 8 37 PHONE 0 WITH AREA CODE <br /> w <br /> Costa Mesa 5 Qvn� CA _9006x1- 127°19- (714)572-71955 ? <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO 14F4+ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ fbv biM4aW t SELF INSURED 2 GUARANTEE O 3 INSURANCE Q 4 SURETY BOND <br /> O 5 LETTER OF CREDIT Q S EXEMPTION O 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.D IL= III.® <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFAlY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED 6 SIGNED) OWNERS TITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION If FACILITY• <br /> 30 FFF A311 h8z � y <br /> LOCATpNCODE�ITpAuc CENSUS TRA T# O�6 SUPVISOR-DISTRICT CODE -OPTIONAL <br /> () 37-2 <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 /> OWNER MUST FILE THIS FORE' "TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO' STORAGE TANK REGULATIONS <br /> FORMA(393) Fp10D13Afl1 <br />