Laserfiche WebLink
STATE OF CALIFORNIA law -y mew o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> . . <br /> COMPLETE THIS FORM FOR EAC ILfrY/SITE <br /> MARK ONLY Q I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O ] PERMANENTLY OLD aSITE <br /> ONE ITEM O 2 INTERIM PERMIT O d AMENDED PERMIT <br /> O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> NAME OF OPERATOR <br /> ADDRESS /11CJYj Z,.-A <br /> paK%nR NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CIT—NAME a73s �tJ _ iec . 0 4e— - <br /> [ STATE ZIP CODE -AREA <br /> -� <br /> SL L SITE PHONE#WITH AREA CODE <br /> CA a01 50© <br /> ✓ EDA TO INDICATE CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY ATE AGENCY <br /> DISTRICTS f� FEOEMLAGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.F A. I.D.#(opl/ w) <br /> O 3 FARM 4 PROCESSOR 5 OTHER O RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) - PHONE 0 WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> do I <br /> NIGHTS: ME(LAST,FIRST) 6 - S� 5Q/ri.0 <br /> PHONE AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> I NE 9 WITH AREA Con <br /> SQ i7L.[� <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME <br /> CAR <br /> EOFADDRESSINFORMAT N <br /> v k o <br /> MAILING OR 3,E!ET RESS ✓ bw bintlba(e INDIVIDUAL <br /> Q 2 LOCAL-AGENCY CD STATE-AGENCY <br /> a JOX r/O 3 a CORPORATION L-1 PARTNERSHIP .lam COUNTYAGENCV O FEDERAL-AGENCYCITY NAME <br /> STATE ZIP CODE PHONE WITH AREA CODE <br /> C4 oZQ - <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 5 <br /> MAILING OR STREET ADDRESS ✓ box blMbate INDIVIDUAL 0 LOCAL-AGENCY O STATEAGENCY <br /> D CORPORATION Q PARTNERSHIP O COUNTY-AGENCY = FEDERALAGENCY <br /> CIN NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUAL 10 UST STOR EE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ4 4 - O" <br /> 0WAZA w;/1 " av ^C <br /> V. PETROLEUM UST SIBILITY-(MUST BE COMPLETED)-IDENTIFY THEMETHOD(S) USED <br /> ✓ box biMbaNEVII SELF-INSURED = 2 GUARANTEE 3 INSURANCE Q A SURETY BOND <br /> l= 5 IETTEROFCREDIT E=1 6 EXEMPTION 0 W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless 1;1911 or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.EK II.O 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(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION aa� FACILITY# <br /> F370/ QSUPVI <br /> °'" <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL - ISTRICT <br /> 0/ 1 '�3 510 1 '1--,3 <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) <br /> F1MI6033A5 <br /> �� kq <br />