Laserfiche WebLink
w46ou- ea�o <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA o �D <br /> G COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY D I NEW PERMIT 3 RENEWAL PERMIT �S CHANCE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT d AMENDED PERMIT Lj B TEMPORARY SITE CLOSURE <br /> I, FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> vl ®rLC r — <br /> ADDRESS NEAREST CROSS STREET PARCEL►(OPTIONAL) <br /> CITY NAME STATEZIP CODE TE PHONE 0 WITH AREA CODE <br /> CA �7 04-0 41 3-`1!4`V <br /> ✓ SIJX CORPORATION l� INDIVIDUAL 0 PARTNERSHIP )]LOCAL-AGENCY COUNTY-AGENCY E STATE-AGENCY I� FEDERAL-AGENCY <br /> TO tNDICATf DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION a 2 DISTRIBUTOR ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.X(oprknal) <br /> RESERVATION <br /> 3 FARM E::] A PROCESSOR I� 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME{LAST.FIRST) PHONE 0 WITH AREA CODE <br /> ' <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRS 17 PHONE•WITH AREA CODE <br /> f� <br /> A. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF DORES INFORMATION <br /> _G�rtlt� 011-C & Circ'°, �i/ l�it��-�,r te'7 , ' 'i4k ,j6P-r <br /> MAILING OR STREET ADDRESS ✓ boa to Indicate INDIVIDUAL LOCAL-AGENCY © STATE-AGENCY <br /> ZoRPORATION PARTNERSHIP 0 COUNTY-AGENCY E-71FEDERAL-AGENCY <br /> 6-TY NAME � . l — v STATE ZIP CODE PHONE x WITH AREA CODE <br /> /LL1�I ZA— C?f� <br /> III, TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OFF OWNER <br /> CARE OF��ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS box dcate Q INDIVIDUAL © LOCAL-AGENCY STATIC-AGENCY <br /> r� r � �? CORPORATION = PARTNERSHIP [ COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE X WITH AREA CODE <br /> C , <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2562 if questions arise. <br /> TY(TK) HQ 4 41-� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or A is C ked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <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 d SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION A FACILITY M <br /> bauT I g I j vr�c"vN <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> - 'Z) '3z " <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.fOROW3A 92 <br /> FORM A(9 90) <br /> 1 <br />