Laserfiche WebLink
i <br /> STATE WASTATE OFCAL'FORNIA <br /> TER RESOURCES CONTROL BOARD • <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM A <br /> o <br /> MARK ONLY ❑ I NEW PERMIT COMPLETE THIS FORM FOR EAC ACILRYBRE <br /> ONE ITEM ❑ 3 RENEWAL PERMIT �,nanr^ <br /> ❑ 2 INTERIM PERMIT 5 CHANGE OF INFOgMgiK)ry <br /> ❑ < AMENDED PERMIT Y C� SITE <br /> I. FACILITY/SITE INFORMATION&ADDRESS. ❑ S TEMPORARY SITE CLOSURE 7 PERMANENTLY <br /> D13AOR FACILITYNAME (MUST BE COMPLETED) <br /> S x /Cj� �v NAME OFOPERpTOR <br /> ADDRESS �+ �(`.� <br /> 3 - �/(� Ct f NEAREST CR STgEET <br /> CITY NAME <br /> -o 4`„/� PARRCEL (OPfpNAU / <br /> ✓Boz STATE ZIP DO O "CE"0( <br /> TO INDICATE CORPORATION ED CA 'f SITE P ONE,,WITH EA CODE <br /> INDIVIDUAL 0 PARTNERSHIP !� -Z?aa <br /> TYPE OF BUSINESSO LOCAL-AGENCY 1:1 CpUNfy-gGENCV <br /> ❑ 1 GAS STATIONED 2 DISTRIBUTOR DISTRICTS Q STATE-AGENCY <br /> ❑ 3 FARM ❑ ✓ IF INDIAN A OF TANKS AT SITE E.P.A. IDA/0 FEDEMLAGEACY <br /> ❑ < PROCESSOR 5 pTHER RESERVATION 1 <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> DAYS: NAME(LAST,FIRST) PHONE A'.WIARDE EMERGENCY CONTACT PERSON (SECONDARY) <br /> . <br /> TH E <br /> NIGHTS: NAME(LAST,FIRST) \J 33 � DAYS: NAME(LAST,FIRST) J OPt10081 <br /> PHONE A WITH AR p OppE PHONE A WITH AREA CODE <br /> NIGHTS:NAME(LAST,FIRST) <br /> PHONE A WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION UST BE COMPLETED <br /> MAILING OR SET ORE <br /> CARE OF ADDRESS INFORMATION <br /> TREAD <br /> 7 _ ✓box 10 Indicate <br /> CITU NAME 0 CORPoRATION INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> STATE 0 PARTNERSHIP 0 COUNTYAGENCY 0 FEDERAL-AGENCY <br /> C ZIP CODE PHONE A WITH AgEA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOFOWNERJ <br /> CARE OF ADDRESS INFORMATION <br /> AILRiGO STR✓FET S <br /> box b Indkaw <br /> CITY NAME O CORPORATION MORAL 0 LOCAL-AGENCYPAR0 STATE-AGENCY <br /> ZIP LADE PARTNERSHIP �]COUNrYAGENCY 0 FEDERAL AGENCY <br /> r» _� PHONEi WITH AgEA ppDE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916) 739-2�582�ifJquesUons arise. <br /> TY(TK) HQ [4T4 -1 W� <br /> r, LtTiAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> TH/S FORM HAS BEEN COMPLETED UNDERPENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE,IS Ta AND CORRECT II.❑ <br /> APPLICANTS NAME(PRINTED&SIGNATURE) <br /> APPLICANTS TITLE <br /> DATE MONTH/DAVNEAR <br /> LOCAL AGENCY USE ONLY <br /> COU <br /> nrtv# <br /> JURISDICTION# <br /> FTTIF�A��Cl/�LIITfYY##��j,7� G� / �/ <br /> LOCATION CODE -OPT/ONAL CENSUS TRACT A -ppi)p)yAL �� r <br /> SYN OR-DISTRICT CODE -OPTIONAL <br /> ,C-'3 Z'7 <br /> ZNI$EORMMU$TBEACCOMPWED BYATLEAST(1)OpApREPERMITAPPLICATpN. g <br /> wawa Is-ea1 FORM B,UNLESS THIS IS A CHANGE OF SRE INFORMATION ONLY. <br /> FORD633A-R2 <br /> 107 <br /> • ✓ ,01 <br />