Laserfiche WebLink
r <br /> STATEOFCAUFORNIA s`4m�,• •• s: <br /> STATE WATER RESOURCES CONTROL BOARD <br /> " UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORMA o^N <br /> COMPLETE THIS FORM FOR EACH FACILITYMITE <br /> ❑ 3 RENEWAL. PERMIT � 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE <br /> MARK ONLY ❑ ) NEW PERMIT <br /> 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT Ela TEMPORARY SITE CLOSURE <br /> ONE REM 11 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) oPEflproR <br /> nRA OR FACILITY NAM LG L—r /y7H12�iET 1'L/,0D m/9 <br /> (: C) NEARESTO L &76 V I PARCEL#(OPTIONAL) <br /> l �� X99 �Ac�9ORN&- <br /> /DRESSSTpCA � /,. SITE PHONE I1 WITH AREAf�7 � <br /> CITY NAME r te-p( S 1 <br /> s7oe�T© LOCAL-AGENCY O COUNTY AGENCY' O STATE. <br /> AGENCY FEDERAL-AGENCY'./ Box ED CORPORATION INDIVIDUAL PARTNERSHIP DGTRICTS' the UST <br /> — — <br /> TOINDICATE <br /> •ry owner d UST Is a public agency.complete the folloMng:name W Supervkor W division.section,pt office which IF(INDIAN a OF TANKS AT SITE E.P.A. I.D.#(aW«m�) <br /> TYPE OF BUSINESS r GAS STATION ❑ 2 DISTRIBUTOR �ORRESERVATION <br /> O 3 FARM Q 4 PROCESSOR ❑ S OTHER <br /> EMERGENCY CONTACT PERSON (SECONDARY)•OPtlonal <br /> EMERGENCY CONTACT PERSON (PRIMARY) PHONE#WITH AREA C <br /> P ONE a WITH AREA CODEp—'If� DAYS: NAMEp(LAST, -�� r[-- <br /> DAYS: NAM E(LAST,FIRST) /�.-�'�.7�(! �/ lT J CY <br /> "/�/ j] �y'L 11� WC �PH Ea WITHA�DE� <br /> /1 T 7F A/7 /� +p �pNEa WI HAREA <br /> �CODE NIGHTS: <br /> /NAM/E( T,FIRST) <br /> NIG S: �ME(LAST <br /> FIRST C7.0 <br /> 11, PROPERTY OWNER INFORMATION- MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME )qYES-# <br /> 1 ,/ boloindicaN INDIVIDUAL LOCALAGENCY 0 EDERAGENCY <br /> MAILING OR STREET ADDRESS 000RPORATION PARTNERSHIP E)COUNTY-AGENCY <br /> FEDERAL-AGENCY <br /> r ✓ T�D` �� STATE ZIP CODE PHONE a WITH AREA CODE <br /> CITY NAME �T ^© } <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAOFP jiiHryEuf, �AA+1FF� s ' H 4�� <br /> �� �/ bot b iMkale 0 INDIVIDUAL 0 LO COUNTY <br /> AGENCY O STATEAGENCV <br /> MAILING OR <br /> /EET ArODRESS •�� �Q. 0 CORPORATION L&PARTNERSHIP PH N E0WITH AC FEDERAL-AGENCY <br /> V ,'(/I PH'O�NYEpa WITH AREA CO �, ^C) <br /> /� // $TATE ZI4 P4&1 ?2 <br /> OCV7 GWr-- ( <br /> CITY Np�M•E O 1, rl / V/V C '7`7x <br /> E ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> IV.BOARD OF EQUALIZATION UST STORAGE FE <br /> TY(TK) HQ 4 4- <br /> 69 - S6a� <br /> V. PET T FINANCIAL RES ONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE MH1= <br /> ODES) USED ` R�eoNo <br /> Q 1SELF-INSURED O 2 GUARANTEE 0 99 OTHER <br /> ✓�tbbdkab 6 LETTER OF CREOT 6 E%EMPTION <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notilication 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 /> I.5C II.❑ it.El <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF My KNOWLEDGE,IS TRUE AND <br /> NON=�YJYZEARCORRECT <br /> �- OWNER'S ON <br /> OWNERS NAME(PRINTED S SIGNED) <br /> yi�1P <br /> 9,4" Qize�, T D a3 aas <br /> LOCAL AGENCY USE ONLY FACILITY# <br /> C�OUNTY <br /> calq# JURISDICTION# <br /> CENSUS TRACcT1a-OP NAL S�ISOR-DISTRICT CODE -OPTIONAL <br /> LOCATION COD -OPTIOMAL �Ji <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)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 STORAGE TANK REGULATIONS <br />