Laserfiche WebLink
w OUP t9 <br /> STATE OFCALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD �' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A °� °a <br /> COMPLETE THIS FORM FOR EACH Y/SRE . G,i ro' - <br /> O Y <br /> MARK ONLY Q r NEW PERMIT E] 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT Q < AMENDED PERMIT <br /> 0 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 8 ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> SM 19R ^T NAME OF OPERATOR <br /> ADDRESS 5a^,. NTNa^a Or VGv <br /> IS'3 3 L )k iI s NEAREST CROSS STREET PMCEL4(0 ANAL) <br /> CITY NAME <br /> STATE ZIP CODE SITE 5 PHONEi WITH AREA Cv CA ODE <br /> ✓ BOX <br /> TO INDICATE O COR ON INDIVIDUAL O PARTNERSHIP ED LOCAL-AGENCY <br /> DISTRICTS <br /> COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> TYPE OF BUSINESS GAS STATION 0 2 DISTRIBUTOR ✓ <br /> ATION OIF INDIAN a OF TANK$AT SITE E.P.A. L D.i(RGfiwwll <br /> Q 3 FARM 0 A PROCESSOR O 6 OTHER OR TTRUSTVLANDS `Q <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 i WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS - - - - -- <br /> ✓'Ga"Kak O INDIVIDUAL F=--) LOCAL-AGENCY l�STATE AGENCY <br /> CITY NAME _ -- — - -. _ O <br /> CORPORATION Q PARTNERSHIP Q COUNTY AGENCY 11:1 FEDERAL#GENCY <br /> STATE ZIP CODE PHONE IN:WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS - - -- - - ✓ W.bibiaaa = INDIVIDUAL E::] LOCAL-AGENCY STATEAGENCY <br /> O CORPORATION O PARTNERSHIP 0 COUNT/-AGENCY E71 FEDERAL-AGENCY <br /> NAME STATE 21P CODE PFIONEi WITH ARE-CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HO [4-F4 - <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner CHEunl—ess/box I or II is checked. <br /> CK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. /Y-- <br /> 11 <br /> IO III.O <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 6 SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY X JURISDICTION p FACI � S7Z0(� .� <br /> � <br /> IKIILr�,-�rLT- <br /> LOCATION CODE -OPTpAML CENSUS TRACTa -OPTIONAL SUPVISOR-DISTRICTCODE -OPTN)NgL <br /> C7 1 1 -X ,3 /S cD17/7/9 Z � <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(990) F01999MAA2 <br />