Laserfiche WebLink
• � � rtb�up t c <br /> wr 4r <br /> STATE OFCALIFORWA r o <br /> STATE WATER RESOURCES CONTROL BOARD W a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE �I`" <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT S CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT a TEMPORARY SITE CLOSUR <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAME OF OPERATOR <br /> r <br /> BA FACILITY N E , NEAREST CRO'51SS STREET PARCEL#(OPfIONAL) <br /> DDRESS <br /> STATE ZIP CODE r SITE PHONE y WITH AREA CODE <br /> CITY NAM rH C <br /> ✓ BOX CORPORATION [] INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY' ] STATE-AGENCY' FEDEML•AGENCY' <br /> TO INDICATE DSTRICTS' <br /> I <br /> i owner d UST is a public agency,mrrplete the following:n f Supery sor of division,sect on,or office which operates the UST <br /> I GAS STATION 2 DISTRIBUTOR o ✓ IF INDIA�#OF ANKSAT SITE E-P,A. I.D.#(oplional) <br /> �] RESERVATIO3 FARM 0 4 PROCESSOR 5 OTHER ORTRUSTLAND <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal <br /> DAYS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NVGWTS: NAME(LAST,FIR T) <br /> PHONE#WITH AREA CODE Ni TS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER FORMATION- MUST BE COMPLETED CARE OF ADD SS INFORMATION <br /> NAME <br /> ✓ <br /> MAILING OR STREET ADDRESS boxbIndicate INDIVIDUAL [71LOCAL-AGENCYSTATE-AGENCY <br /> Q CORPORATION PARTNERSHIP C] COUNTY-AGENCY DFEDERAL-AGENCY <br /> STATE ZIP GOD PHONE#WITH AREA CODE <br /> CITY NAME <br /> Ill. TANK OWNER INFORMATION MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFO RMATIN <br /> MAILING OR STREET ADDRESS ✓ box talndicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> (]CORPORATION PARTNERSHI COUNTY-AGENCY [-_] FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME <br /> IV.BOARD OF EQUALIZATION UST STORAGE F ACCOUNT NUMBER-Call(9116)322-9669 it questio s arise. <br /> TY(TK) HQ 4 4- <br /> V, PETROLEUM UST FINANCIAL RESPONSIBILITY-(M ST BE COMPLETED)—IDENTIFY THE METHOD(S) SED <br /> I I SELF-INSURED 712 GUARANTEE [] 3 INSURANCE []4 SURETY BOND <br /> baxbindcate <br /> 0 5 LETTERDFCREDiT =e EXEMPTION 49 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal noliticalion and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOx INDICATING WHICH A8OVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[--] Il.[�] III. <br /> THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME tPRINTED&SIGNED) <br /> OWNER'S TELE DATE MONTHIDAYIYFJ4R <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# `VA <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPT MAL SUPVISOR-DISTRICT CODE -OP <br /> I <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3193► �` � <br />