Laserfiche WebLink
'a t0 <br /> STATE OFCALIFDRNIA <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A <br /> COMPLETE THIS FORM FOR EACH FA LITY/SITE <br /> MARK ONLY 7 RENEWAL PERMIT <br /> I NEW PERMIT 5 CHANGE OF INFORMATION � 7 PERMANENTLY r.SOSEO SITE <br /> � <br /> ONE ITEM CJ 2 INTERIM PERMIT Q d AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEARESTCR STREETPM CEL 0(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE 0 WITH AREA CODE <br /> CA q BOX _ <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY Q CDUNTY-AGENCY• Q STATE-AGENCY• Q FEDERAL AGENCY' <br /> woffice <br /> DISTRICTS' <br /> If owner d UST Is a public agency,mnplete the following:name of Supervisor of dwiion.section,IS o#ice whkh operates the UST <br /> TYPE OF BUSINESS i GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN IS OF TANKS AT SITE E.P.A. 1.D.#foplbnalt <br /> RESERVATION <br /> O 3 FARM O A PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA7COOENIGHTS: ME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LASTFIRST) <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NACARE OF ADDRESS INFORMATION <br /> MAILING OR STREE ADDRESS ✓ box biebicaro Q INDIVIDUAL Q LOCAL.AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) l/1�..* <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> W <br /> MAILING OR STREET ADDRESS ✓ boa birdicate Q INDIVIDUAL Q LOCAL AGENCY Q STATE AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY AGENCY Q FEDERAL4GENCY <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 4 W- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa bbCbate O I SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE <br /> Q d SURETY BOND <br /> 0 5 LETTER OF CREDIT Q 6 EXEMPTION Q 90 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless bo or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.e II.0 III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY At I b <br /> 2 o u-21�1619 <br /> LOCATION CODE -OPTIONAL CENSUSTRACT# -OPTIONAL SUPVISOR-DISTRICT CODE .OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PER APPLICATION- FORM B,UNLESS THIS IS A CHAITE INFORMA <br /> FORMA(3/83) N 0 Y <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS T� � <br /> F017ge)NA7 <br />