Laserfiche WebLink
STATE OF CALIFORNIA ` <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> CCOMPLETE THIS FORM FOR EAC FACILRYISITE <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> A DRESS NE a CROSS STREET PARCEL#(OPTIONAU <br /> o I,cJ <br /> CITU NAME STACA ZIP CODE SI EPHO RWITH AREA COD <br /> TOI/ Box <br /> INDICATE CORPORATION E-1INDIVIDUALO PARTNERSHIP LOCAL-AGENCY O COUNTY EDSTfATTE--AGEN ATOL FEDERALAGENCY <br /> DISTRI <br /> TS <br /> TYPE OF BUSINESS a 1 GAS STATION 2 DISTRIBUTOR / <br /> RESE F INDIAN <br /> ION M OF TANKS AT SITE E.P.A. L D.#(optional) <br /> O 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS �--' <br /> EMERGENCY CONTACT PE SON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAY NAME(LAST,FIRRSST) HONE It AREA COD —� DAYS: NAME(LAST,FIRST) <br /> ) VASQ1&eS aLdhd DF <br /> NIGHTS: NAM (LAS*,FIRT) PHONE*WITH EA CODE NIGHTS: NAME(LAS ,FIRST) <br /> 'S cz'-r� S &-Ts� PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRESS ✓ boa to Indicate INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> O CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NA OF OWNER CARE OF ADDRESS INFORMATION <br /> w <br /> M IL OR STREET ESS ^,J boa blMkale 0 INDIVIDUAL f7 LOCAL-AGENCY 0 STATE-AGENCY <br /> 4 a � N CORPORATION 0 PARTNERSHIP COUNTYAGENCY O FEDERAL AGENCY <br /> CITY NAGE O ST! ZIP CODE a PHONE i WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(91 6)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boabiMkala O I SELF-INSURED 0 UARAWEE Q 3 INSURANCE Q 4 SURETY BOND <br /> 5 LETTEROFCREDIT EXEMPTION Q W OTHER <br /> 771 <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.O IL O III. <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 S SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY — 6 <br /> COUNTY# JURISDICTION# �� FACILITY <br /> �� <br /> CIILIITY��u <br /> �) <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICTCODE -OPTIONAL <br /> THISFO M M ST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) V FO/R(XIMA5 <br />