Laserfiche WebLink
STATE OFCALIFORWA <br /> STATE WATER RESOURCES CONTROL BOARD �±S <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE °•<<.on,'' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE E <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACIL TY NAME NAME OF OPERATOR <br /> ADDRESS NEARqSTCROSSSTREETPARCEL#{OPTIONAL] <br /> � v <br /> CITY NAME STATE ZIP COD SITE PHONE#WITH AREA CODE <br /> CA � 3 7-4: <br /> BOX <br /> T NDIC TE CORPORATION (] INDIVIDUAL 0 PARTNERSHIP Q LOCAL-AGENCY 0 COUNTY-AGENCYSTATE-AGENCY- O FEDERAL.AGENCY' <br /> DISTRICTS' <br /> li owner of UST is a public agency,complete the following:name of Supervisor of division,section,or oltice which operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR IF INDIAN IN OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RES✓ERVATION <br /> Q S FARM 0 b PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAIMELAST,FIRST) HONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> v <br /> NIGHTS: NAME(LAST,FIRST PHONE#WiTH AREA CODY NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMECARE OF ADDRESS INFORMATION <br /> 1�. / l <br /> MAILING OR 5 REFT ADD RE ✓ box b indicate INDIVIDUAL LOCAL-AGENCY [] STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME Q STATE ZIP CODE PHON #WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWN R CARE OF ADDRESS INFORMATION <br /> %.�� <br /> MAILING ORS BEETADDRE S wry/ ✓ boxIDindicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY I] FEDERAL-AGENCY <br /> CI NAME STATE ZIP CODE HONE#WITH AREA CODE <br /> �� d �� 37 Za-S 3 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bIndicate 1 SELF-INSURED [::12 GUARANTEE E::] 3 INSURANCE 4 SURETY BOND <br /> Q 5 LETTER OF CREDIT ©6 EXEMPTION M 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. I It.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,ISTRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAY/Y'EAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL C� S TRACT# -OPTIONAL SUTMS DISTRICT CODE -OPTIONAL <br /> THI4 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 FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND ST AGE TANK REGULATIONS <br /> FORMA(3193) FOR0033A-R7 <br />