Laserfiche WebLink
40Soon e. <br /> e <br /> STATE OF CALIFORNIA P. ...... <br /> •,•• cOi <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a�� v <br /> O <br /> COMPLETE THIS FORM FOR EACH FACILrrY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT [j—Z] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE r) <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) J <br /> DBA OR FACILITY NAME SW <br /> /^ NAME OF OPERATOR trtOQ `) <br /> _ ,4,:,-_, 4- gU Cid/ <br /> t <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 4114 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE. <br /> -- L G r -_ CA S-3 $-58- u isi- <br /> ✓ BOX �- <br /> TO INDICATE C CORPORATION F1 INDIVIDUAL E:1 PARTNERSHIP F=1 LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION _] 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM U 4 PROCESSOR 0 5 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) ( PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> Sq( ~ J _ _.C��) V,5'B—Z(A-r PHONE a WITH AREA cmF: <br /> NIGHTS: NAME(�T) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> ✓CEJ Wx-) G 3 PHONIF#WITH AREA CODE <br /> II: ROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NA // CARE OF ADDRESS INFORMATION <br /> 114ceV AooOdG <br /> MAILING OR STREET ADDRESS ✓box toindicate INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> &jZ( 6© 3 g O CORPORATION PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> It- S t� g �jb7o2— (�O <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> _9.nL 4-S <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL <br /> LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION Q PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 14 4]-0 n 01 SC) I G <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate J 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> 5 LETTER OF CREDIT (]6 EXEMPTION C]99 OTHER <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: 1.0 11.7 III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# QCoS �s <br /> 39 I I I ( 6s <br /> OCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL I SUPVISOR-DISTRICT CODE -OPTIONAL <br /> -3z� -30� <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 /> A; FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATI <br /> FOR0033A-R6 <br />