Laserfiche WebLink
�60UR YH <br /> STATE OF CALIFORRIA .t <br /> STATE WATER RESOURCES CONTROL BOARD <br /> -`� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FA ffY/SITE t <br /> C��I'QR Nin <br /> ff f i <br /> I i <br /> MARK ONLY 1 NEW PERMIT❑ ❑ 3 RENEWAL P[RMII 5 CHANGE OF INFORMATION PERMANEN SITE t <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 9, <br /> FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAM NAME OF OPERATOR <br /> ADDRESS r} f `� NEAREST CROSS STREET PARCE <br /> r7 Jfy(J.'1 Y <br /> CITY NAME STATE ZIP CODE, SITL PHONE a WITH AREA CODE <br /> TOINDI�C TE CORPORATION []INDIVIDUAL PARTNER IP [] L(X;AL-AGENCY AL -AGENCY <br /> STATE.AGENCYFEDERII AGENCY' <br /> DISTRICTS' <br /> 'It owner of UST Is a public agency,complete the following:namo of Supervisor of division,section,or office which oporales the UST <br /> TYPE OF BUSINESS C� 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a(cy ionap <br /> RESERVATION <br /> 3 FARM ❑ 4 PROCESSOR [ 5 UTHER 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 a WI I II AREA CODE <br /> NIGHTS:NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE_ <br /> II. PROPERTY OWNER INFORMATION (MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate F—] INDIVIDUAL F�:] LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION [__j PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STX­TE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> I�CORPORATION (] PARTNERSHIP COUMY-AGENCY �f FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE I PHONE;;:WITH AREA CODE 1 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNTNUMBER-Call(916)322-9669 if questions arise, II <br /> TY(TK) HQ F4__[4_-1- _ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY- UST BE COMPLETED)—IDENTIT=Y THE METHOD(S) USED <br /> + ✓bot bindicate t SELF-INSURED 2 GUARANTEE 0 3 INSURANCE []4 SURETY BOND <br /> 5 LETTEROFCREDIT 6 EXEMPTION Q 96 OILER <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: L[__j II. _I hl. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRIJE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEJAR <br /> LOCAL AGENCY USE ONLY Gam_ <br /> COUNTY# r / JURISDICTION# FACILrTY# <br /> y LOCATION C.OD,E - <br /> __XAL (CENSUS TRACT a TIONAL SUPVISOR•DISTRICT CODE -OPTIONAL \�� <br /> Al <br /> THIS FOR MUST BE ACCOMPANIED BY AT LEAST 1) R MORE PERMrt'APPLICATION- FORD B,UNLESS THIS IS A CHANGE OF STf'E INFORMATION HLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA{3193) FORA337AA7 <br />