Laserfiche WebLink
0 ooA e <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ;yP fo <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> Cl)"i <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 P TLV LOBED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5Q <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BEC MPLETED) <br /> DBA OR FACILITY NAME NAMEOFOPERATOR <br /> � r <br /> ADDRESS I �J C� NEAREST CROSS STREET PARCEL u(OPfgNAL)�'L�/ } J <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓ BOX <br /> TO INDICATE O CORPORATION 0 INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY AGENCY [::j STATE AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR O ✓ IF INDIAN #OF TAN AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM ] 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) I PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) OF <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CO! <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box lolMkaie INDIVIDUAL = LOCAL AGENCY D STATE-AGENCY <br /> l�CORPORATION (] PARTNERSHIP =COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box Mkal# 0 INDIVIDUAL E-1 LOCAL AGENCY 0 STATE-AGENCY <br /> l�CORPORATION 0 PARTNERSHIP M COUNTY-AGENCY [—I FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORXGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4. A �2 V. <br /> V. PETROLEUM UST FINANC AL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> \_ _ ✓ box blMkate I SELF-INSURED 2 GUARANTEEJ INSURANCE d SURETY BOND <br /> I 5 LETTER OF CREDIT O 6 EXEMPTION Q 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 /> APPLICANTS NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYYEAR <br /> LOCAL AGENCY USE ONLY U <br /> COUNTY# JURISDICTION# FACILITY# <br /> if <br /> pDv <br /> LOCATION CODS - <br /> OPTIONAL CENSUS TRACT#-OPTIC L SUPVISOR-DISTflICTCODE -OPTiCNAL <br /> 0 � <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION• FOR B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> fi <br /> FORMA(591) <br /> ` FORO 5 (� <br />