Laserfiche WebLink
a<oo, r <br /> STATE OF CALIFORNIA <br /> / STATE WATER RESOURCES CONTROL(B D p 3y : <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A <br /> N' <br /> 4^p V <br /> COMPLETE THIS FORM FOR EAC ACILITYISITE <br /> MARK ONLY O T NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E�j 7 PERMANENTLY CLO <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE 5 Z. <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> D AOR FACILITYNAMENAMEOFOPERATOR <br /> II <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTONAD <br /> 3788 T L)L /AtCe� Nlc-4�1�Ia`( a <br /> CITY NAME STATE ZIP CODE_ SITE PHONE#WITH AREA CODE <br /> CA1� BOX <br /> TO INDICATE Ev4oRPORATION INDIVIDUAL Q PARTNERSHIP 0 LOCAL-AGENCY Q COUNTY-AGENCY STATE AGENCY FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION O 2 DISTRIBUTOR O ✓ IF INDIAN A OF TANKS AT SITE E.P.A. L DD..#.(OPNm#)) <br /> 3 FARM Q 4 PROCESSOR O 5 OTHER OR TRUSTLLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST I PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) '✓1� ��� <br /> NIGHTS NAME( T,FIRST PHONE#WITH AREA CODE NIGHTS: NAM (LAST,FIRST -7Z�-7l0t <br /> L�.a. �i �7 [oC,'tJ JI-lGC-Pl.E�1 � <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> N1AM'E1 CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS �y,, �, ✓ EO�binOb#a INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY <br /> Olt 1�I L1�i rjLJ Jl.� � � Ev RPORATON PARTNERSHIP = COUNTVAGENCY FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> LLG+r� ( C.Io. 96771 ?il7j �-7lOC�S <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> L� <br /> MAILING OR STREET ADDRESS ✓ Eoi bvbicab INDIVIDUAL O LCCAL AGENCY 0 STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ F4-F4]- <br /> 0 0 O <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE CO PLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ Eoa blydkaN i SELF-INSURED T GUARAMEF 7 INSURANCE Q 1 SURETY BOND <br /> D 5 LETTEROFCREDR = 6 EXEMPTION O W 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: L❑ I.Ez III. <br /> THIS FORM HAS BEEN COMPLETED UNDER P TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED B SIGNATURE) APPLICANT'S TITLE DATE MONTWDAYNEAR <br /> 03:2j&W -C-z>RMtcK- rT= o }� 11�-9z <br /> LOCAL A EN Y USE ONL <br /> COUNTY# JURISDICTION# FACILITY# <br /> ® ��1ID ►� 31 0 1 <br /> LOCATION CODED DONAL (CENSUS TRACT a -OPTIONAL I SUPVISOR TR C CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAS (1)OR MORE PERMIT APPLICATION• FORM B,UNL HIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FORDWJA 5 <br /> 1j J <br />