Laserfiche WebLink
• STATE OF CALIFORNIA • ^eb un ^ °o <br /> STATE WATER RESOURCES CONTROL BOARD W` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> C�LI�O�M� <br /> COMPLETE THIS FORM FOR EACH F RYISITE <br /> MARK ONLY 3 NEW PERMIT O 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY D SITE <br /> ONE ITEM 2 INTERIM PERMIT O d AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME // NAMEOF OPERATOR <br /> ^ u w'� Co feu <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPrIONAI) <br /> CITU NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> S rrk CA <br /> ✓ Box <br /> TO INDICATE O CORPORATION D INDIVIDUAL =PARTNERSHIP D LOCAL-AGENCY O COUNTY-AGENCY O STATE-AGENCY <br /> DISTRICTS FEDERALAGENCV <br /> TYPE OF BUSINESS O 3 GAS STATION 0 2 DISTRIBUTOR / IF <br /> IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM O d PROCESSOR O 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS. NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bo"Iridal# INDIVIDUAL DLOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNfRAGENCY 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- ✓ b XkIiWicale Q INDIVIDUAL O LOCAL-AGENCY (]STATE AGENCY <br /> =CORPORATION 0 PARTNERSHIP = COUNTYAGENCY 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 LZ]-n � <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ w om kala I SELF INSURED 2 GUARANTEE 3 INSURANCE ED 4 SURETY BONG <br /> 5 LETTEROFCREDIT 6 EXEMPTION 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: <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 MONTWDAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> -- - <br /> LOCATION CODE OPTIONAL (CENSUS TRACT# 0P710NAj SUPVISOR-DISTRICT CODE -OPTONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE TINF��ATI ONLY. <br /> FORM A(I2 9n FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS0 0 FOR0033A R6 <br />