Laserfiche WebLink
• • czou- ey I <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> s , o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED S E <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> 114 IZt, 4 5 4 �oS <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME � STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> 5' cl[c �ve CA <br /> N <br /> T DIICCATE E]CORPORATION INDIVIDUAL I= PARTNERSHIP O LOCAL AGENCY 71 COUNTY-AGENCY E:j STATE-AGENCY =1 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR ❑ RE/ IF INDIOIAN N #OF TANKS AT SIiE <br /> O 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHT AS <br /> NAME(LT,FIRST) `- PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA cnnp <br /> ll. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME e Jr/'/ JC � CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS 7 l ✓box biMkate M INDIVIDUAL 0 LOCAL-AGENCY L_j STATE-AGENCY <br /> L- P N , ( Y�64,&-0" CORPORATION [__1 PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> SAO c� &7 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> _ s � <br /> MAILING OR STREET ADDRESS ✓ box biMicale INDIVIDUAL LOCAL AGENCY STATE AGENCY <br /> =CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO L`�I`'1-� <br /> V. PETROLEUM UST FINANCIAL PONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THEMETHOD(S) USED <br /> ✓ boa bintlicate L. I I SELF INSURED 1-1 2 GUARANTEE Q 3 INSURANCE 0 4 577 7N7 <br /> F 5 LETTEROFCREDT u 6 EXEMPTION I_f 99 OTHER <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: 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 /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWOAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION AGILITY# <br /> a <br /> LOCATIONCODE OPTIONAL ICENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> Z3)-D 3 2 3 15-? Ct, <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(12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> //'jF,0,S613A-R6 <br /> 0 1* <br />