Laserfiche WebLink
` STATE OFCAL1FOIiMA a <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM ACOMPLETE THIS FORM FOR EAC ACIUTY/SITE <br /> MARK ONLYI NEW PERMIT E:] 3 RENEWAL PERMIT © 5 CHANGE OF INFORMATION gNEN Y CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 1 <br /> DBA OR FACIL TY NAME NAME PERA70R <br /> ADDRS NEAR CROSS STREET PARCEL#(OPTIONAL) <br /> W C <br /> CITY NAE STATE ZIP CODE SITE PHONE#WITH AR Q1 <br /> C CA 1 I <br /> TO INDICATE QI CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL AGENCY <br /> OGTFNCTS' \ <br /> 'If owner of UST Is a public agency,complete the foliowng:name of Supervisor of dNubn.section,or office which operate#the UST `�b <br /> TYPE OF BUSINESS 1 GAS STATION a 2 DISTRIBUTORQ RE ERVNDIIAANN #OF TANKS SITE E.P.A. I.0.0 Tgorr) <br /> 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST FINDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST, ST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIR PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> II. PROPERTY OWNER I ORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Eos so hkkaN <br /> Q INDIVIDUAL 011LOCAL AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP QCOUNTY-AGENCY Q FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> I \ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOFOWNER CARE OF ADDRESS INFORMATION \ <br /> MAILING OR STREET ADDRESS ✓ bo4 birdicau Q INDIVIDUAL Q LOCAL AGENCY \Q STATE AGENCY <br /> \� Q ALAGENCYCORPORATION PARTNERSHIP COUNTY AGENCY Q FEDER <br /> CITY NAME `.\ STATE ZIP CODE PHONE#WITH AREA'CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. \ <br /> TY(TK) HQ M44- - <br /> E Q <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa clMieate Q I SELF-INSURED Q 2 GUARANTEEINSURANCE Q 4 SURETY/BOND <br /> Q <br /> Q 5 LETTER OF CREDIT Q 6 EXEMPTION 59 OTHER �T &L, .�/ <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 /> CHECKONE 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,1S TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNEFVSTRL.E DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY F� UG�(�d 5 ' `J ✓ ,�/ <br /> C�O}UUNN�-TAY�# JURISDICTION# q �� A ILrTY# <br /> =17 �i_J �' .. Q --+ �' •rte- ' <br /> LOCATION`CgDE -OPTIONAL CENSUS TRACT# -OPTIONAL 9UPVISOR-DISTRICT CODE-OP NAL <br /> / / X� /� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS 1S A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FOR <br /> W THE LOCAL AGENCY IMPLEMENTING THE UNDERGROWORAGE TANK REGULATIONS <br /> FORM A(G9G) • C FOR0017AA7 <br /> `� J <br />