Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> id <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMITLOSER SI❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY COSEDYTE <br /> ONE ITEM <br /> ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT <br /> ❑ 6 TEMPORARY SITE CLOSURE j <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 7 <br /> DBA OR FACI Y NAME <br /> a <br /> NAME OF OPERATOR <br /> ADDRESS 1�77—.Ir h <br /> �s- sNEEAAREST CROSS STREET PARCEL#(OPTIONAL) <br /> / / FJ <br /> CITY NAME Z� — /� �� <br /> STATE ZIP CODE SITE PHONE#WITHAREA CODE <br /> ✓BOX0 CORPORATION I� INDNIDUAI p CA 9 <br /> TO INDICATE RTNERSHIP O LOCAL-AGENCY E:]COUNTY-AGENCY' <br /> #oxnerof USTBa ub8ea P DISTRICTS STATE-AGENCY' ED FEDERAL.AGENCy• <br /> P genry,complete Mefalbwh.nameds ervisor -Moon.mon or ofr"xfiM operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION O 2 DISTRIBUTOR ❑ ✓IFINDIAN #OF TgNKS AT SITE E.P.A. I.D.R(optional) <br /> ❑ 3 FARM Q 4 PROCESSOR 5 OTHER RESERVATION 11 <br /> OR TRUST LANDS <br /> DAYS: NAMEEMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> LAST,FIRST) P ONE#WITHAREACODE <br /> DAYS: NAME(LAST,FIR T) PHONE R WITH AREA CODE <br /> �N 37l is >az- <br /> NIGHTS: NAME(LAST,FIRST) HONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST, Ig ST) PHONE#WITH AREA CODE <br /> � iso , _�. <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETE <br /> NAME <br /> V (J <br /> • CARE OF ADDRESS INFORMATION <br /> O <br /> MAILING OR STREET ADDRESS <br /> ?w ✓ box W ia9cele Q INDMWAL OLOCAL-AGENCY O STATE-AGENCY <br /> CITY NAME �CORPORATION/� �- (.I O PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> O/��._ STATE ZIP CODE ONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) �rj o a8 �j 37/—6�7ib <br /> NAME OF OWNER `q,.,_ <br /> VAZ—C-� �` ill e_— I CARE OF ADDREBS INFORMATION <br /> MAILING OR STREET ADDRESS W "A''!-Nom•-+/ <br /> ✓ boxlo ndrale p INDIVIDUAL O LDCAL.AGENCY Q STATE-AGENCY <br /> CITU NAME CORPORATION 0 PARTNERSHIP EDCOUNTY-AGENCY0 FEDERAL-AGENCY <br /> C..9 TQC STATE ZIP CODE (ZHO N TH AREA CODE <br /> o1Y . - <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322.9669 if questions arise. <br /> TY(TK) HQ 4 4- 0 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED <br /> ✓box to m?cele ED 1 SELF-INSURED 0 2 GUARANTEE 11 91NSURANCE O I SURETY BOND [:15 LETTEROFCREDR <br /> ED .M 09 <br /> 8 STATE RIND&CHIEF FINANCIAL OFFICER LETTER 09 STATE FUND&CERTIFICATEOFDEPOSIT O10 LOCAL GOVTMECHANISMnO##OTTERTE FUND <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 /> I.❑ II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED 8 SIGNATURE) <br /> TANK OWNER'S TITLE DATE MONTHYDAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION k <br /> FACILITY <br /> ITY# <br /> Z 3 2 � <br /> LOCATION CODE -OPTIONAL CENSUS TRACT R.OPTIONAL <br /> SUPVISOR-DISTRICT CODE •OPTI#NAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B.UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(6-95) OWNER MUST FILE THIS FORW THE LOCAL AGENCY IMPLEMENTING THE UNDERGRre STORAGE TANK REGULATIONS <br />