Laserfiche WebLink
•,'SOW t <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> MERGROUND STORAGE TANK PERMIT APPLI ATION - FORM A <br /> COMPLETE THIS FORM FOR EACH F LITYISITE <br /> MARK ONLY �� 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE IT <br /> 2 INTERIM PERMIT F7 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE t-7 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) J <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> /7 <br /> ADDRESS I NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 4/27 E �/nt11- 7 9 -�) - /7O <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> �n CA 9BOX <br /> sao/ <br /> TO INDICATE Elj=ON INDIVIDUAL I1 PARTNERSHIP O LOCAL-AGENCY (]COUNTY-AGENCY STATE AGENCY O FEDERAL.AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR Q ./ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(oplimap <br /> RESERVATION <br /> O 3 FARM O 4 PROCESSOR 0 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 /> G ZGi vi7-I?YS'- 7676 SaAHR <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ll. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ tWkme INDIVIDUAL E::] LOCAL-AGENCY STATE-AGENCY <br /> a/ � .` ![T /,! sU�>Y' Lj• 7J CORPORATION O PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Gva/ of Cvre� Ch 9 �/rl� YiS-QYS- 767c <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> �1— <br /> MAILING ORSTREET ADDRESS ✓ 9oatln0kme Q INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> =CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE x WITH AREA CODE <br /> I <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ 4 4 - D 3 a s (o <br /> V. PETROLEUM UST FINANCIA SPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓5oa blMkaM 1 SELF INSURED =12 GUARANTEE GI 3 INSURANCE 0 4 SURETY BOND <br /> O 5 LETTEROFCREDIT Q 6 EXEMPTION O 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 WHCH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ III.E] <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 9 0/-'/0,&) <br /> LOCATION CODE -OPTRINAL CENSUS TRACT# -OPTIONAL SUPVISOR DISTRICT CODE -OPTIONAL <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 /> FORM A(5-91) FOR0033A-5 <br />