Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> t <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> .10 <br /> MARK ONLY X' NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE'� F INFORMATION 7 PERMANENTLY CICS] SITE <br /> ONE ITEM 2 INTERIM PEqVi7 4 AMENDED PERMIT 6 TEMPORARY SITE'ICLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS (MUST BE COMPLETED) <br /> DEA OR FACILITY NAME NAME OF OPERATOR <br /> fG <br /> ADDRESS NEAREST CRCSS STREET PARCEL 9(OPTIONAW <br /> CITY NAME STATE ZIP c1OOE SITE PHONE a WiTW A;ZE'A CODE <br /> A <br /> v BOX <br /> E STATE-AGENCY rr=_:AL4GtNCY <br /> 10 INDCATE APOAATION 7Qvz�z_ Ej- PARTNERSHIPLOCAL-AGENCY COUf,7Y-AG NCY <br /> DSTRiCTS 11 !1 <br /> TYPE OF13US!NESS O 1 GAS STATION 7-- 2S7R1;Lj7cR r,/ 'I"N"'AN SOF TANKS AT SITE E.P.A. <br /> 3 FARM ;OCESSCR ESERVATION <br /> 5 OTHER CATRUSTLANDS <br /> EMERGENCY CONTACT (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•qz­,�cnzl <br /> DAYS: NAME(LAST,FIRST) r-Z:%E x WITH AREA CODE DAYS: KAJAE(LAST,"IRRST) <br /> Emj-m , _C�jz_ "21o. (a Z-72.-/-m I 1� GN_tS <br /> NIGHTS: NAME(LAST,FIRST) a WiTH ARE A CODE S: NAME(LAST,FIRST) <br /> te PHONM a W�7 <br /> H. PROPERTY OWNER INFORMATION- (MUST BE COMPLETED) <br /> 7--Atv7E— CARE OF ADDRESS NFORVATION <br /> MAILING OR STREET A=RESSEwt?'e. ✓=0cpp V box z in-'., ;, <br /> LOCAL-AGiNCY 5- -E-I.Z�ENCY <br /> COPIPOR'A:;CN I C FA;TSIERSHip Q COUNTY-AGENCY <br /> CITY NAVE I STATE 1 ZIP CODEREAC-:� <br /> PHONE x;WITH Air <br /> 111. TANK OWNER INFORMATION• (MIUST BE COMPLETED) <br /> NAI,'.E OF OWNE R C�AgE OF A-,:;RESS V%'FORIZATION <br /> MAILING C;i STREET A=RESS ✓ bUtino-cVt 1%4 LOCAL-AGENCY VATIE-AGENCY <br /> D. '117 Is N LJ FA;T:Nz;;SHJP COLNTY-AZEKY --:_'-RAL-AGENCY <br /> CITY NAVC iS7 i E�`y <br /> 2.P CODE PHONE it WjTH AZ;EA C^__ <br /> 6 F <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(9 1 6)323-9555 iiquestionsarise. <br /> TY(TK) HO <br /> 4 4 ,`_'0121 I NEI— <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY- (MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> 2 GuAw.tu 5 tNSL:;;/,NCE <br /> _2 <br /> Z.�;ETY 6_�Q <br /> -=2 6 EXiV.;TICN 7_11 SS C7H-R <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Leoal notification and billing will be sent to 14 lank cwner unless box I or 11 is checked. <br /> .1 -J <br /> FCECX ONE FOI INDICATING W41CH ABOVE USED FOR LEGAL NOTIFICATIONS AND StLING; <br /> THIS FC,;tf HAS BEEN COUPLET INDERF& LTY OF PERJURY,AND TO THE BEST OF.;14Y KN61AILEDGE,IS TRUE AND CORRECT <br /> ii <br /> fi (PR:%_-i1;LSiG%ATUREj TtTLE CATE v_-%TH.c;.Y"yit,:; <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICT!ON a I FACILITY 41 <br /> LOCATION CODE OPTIONAL CENSUS TRACT 9 -OPTIONAL SUPVISOR DISTRICT CODEi-OPTIONAL <br /> j <br /> 2. <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 13,f UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) <br /> t <br />