Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH ILrTY/SITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 0 A AMENDED PERMIT6 TEMPORARY T <br /> SITE CLOSUREV <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) V <br /> DBA OR FACILITY NAME <br /> oe [, NAMEOFOPERATOR <br /> ADDRESS /�'— <br /> � 7S �_ NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME Pe r <br /> STATE ZIP CODE SITE PHONE I WITH AREA CODE <br /> ✓ BOX C 4 9 s Zo f <br /> TO INDICATE 0 CORPORATION O INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY <br /> DISTRICTS D STATE-pGENCV <br /> TYPE OF BUSINESS O 0 FEDERAL-AGENCY <br /> 1 GAS STATION 0 2 DISTRIBUTOR ✓ I�SERF INDIAN I OF TANKS AT SITE E.P.A. <br /> 0 3 FARM O A PROCESSOR 0 5 OTHER OR TRUSTLAI.D.I(optigTelJ <br /> ANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> �o -3 <br /> NIGHTS: NAME ?- Y6s <br /> I.FIRST) PHONE I WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> v) D-G-x-- <br /> MAILING ORSTREETADDRESS ✓ boa bintlk#A INDIVIDUAL <br /> /3o,- oo O CORPORATION 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> CITY NAME O PARTNERSHIP O COUNIV-AGENCV FEDERAL AGENCY <br /> Sit b STATE ZIP CODE PHONE I WITH AREA CODE <br /> G9 9s Z� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boabiMbaN INDIVIDUAL <br /> D LOCAL-AGENCY D STATE-AGENCY <br /> CITY NAME CORPORATION = PARTNERSHIP 0 COUNTY-AGENCy FEDERALAGENCY <br /> STATE ZIP CODE PHONE I WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 14141- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bmicate 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE <br /> D O <SURETY SONO <br /> 5 LETTEROFCREDIT <br /> 0 8 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 II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.F7 III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PR IN TED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# /9V7­0r^3,7 <br /> v7 <br /> LOCATION CODE -QOPTIONAL CENSUS TRACTa -OPTIONAL SUPVISOR-D TRICJC DE -OPTIONAL <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 /> FORM A(5 91) FORW33AS <br /> `ve <br />