Laserfiche WebLink
�6o�R�Es <br /> STATE OF CALIFORNIA °Oti <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> C ORM FOR EAG ' rrY/SITE <br /> MARK ONLY NEW PERMIT 3 RENEW— PERMI \ ( — 6 CHANGE OF INFORMATION 7 PERMA SED SITE <br /> ONE ITEM R 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE (17 <br /> I. FACILITY/SITE INFORMATION& ADD SS-(MUST BLET ED) <br /> CtPR FACILITY NAME <br /> A . ,� f _ NEAR ^TC�SGS('I(n� PARCELx(OPfIONAL) <br /> D E <br /> CITY NM — —-STATE ZIP �l✓ SITE PHONE#WI RV CODE <br /> CA <br /> —✓ Box __ <br /> TO INDICATE CORPORATION INDIVIDUAL PARTNEnS-'' r-I LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS I� t GAS STATION 2 DISTRIBUTOR -/ <br /> IF INDIAN #OF SAT SITE E.P.A. I.D.#(optional) <br /> = RESERVATION <br /> 3 FARM � 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> W <br /> ST,F ST) PHO E#WITH AREA CCDE DAYS: NAME(LAST,FIRST) <br /> lomd(/moi l fg-Sy -DLAST,FIRST) PH E#WITH AREA DCDE NIGHTS: NAME(LAST.FIRST) <br /> PH <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED! <br /> NA lain A(� <br /> _ /) \ CARE OF ADDRESS INFORMATION <br /> M IL R STREET A ESS (Vn'`_T1\— ✓ box 0 indicate 77 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> _ 0 - X 41161 _ _ ^_CORPORATION 7-- PARTNERSHIP n COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAMFjST 7EZR CODE PHONE#WITH AREA CODE <br /> i0/0 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM NE_A CARE OF ADDRESS INFORMATION <br /> --- —- --- <br /> MAIL! RST ET DDRESS ✓ box irWicate <br /> �/�� INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> _CORPORATION J PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY —f�G STATE I ZIP gopE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST S--T0RAGE FEE ACCOUNT NUMBER -Call(916)323-9555 if questions arise. <br /> TY(TK) HQ _4 15 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate t SELF-INSURED ARANTEE L7„ 30supmcf 0 4 SURETY BOND <br /> 5 LETTER OF CREDIT CXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS La^aI notification and billing will be sent to the tank owner unless box I or II i hecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED=CR LEGAL NOTIFICATIONS AND BILLING: L= II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY fF=ERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPL'.CA�JT'S NAVE;PRINTED 8 SIGNATURE! APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# ISID ICT10N# FACILITY# <br /> 3 � -L-4C <br /> CATON C_D; ...PTIONAC „ NSUS _- -�..:�a: S °.•iS.^.R SIS RIC CCDE -OPTIONAL <br /> 13 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERIAT APPLICATION• FORM B,bNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> oW,!A i,,,e'I FILE THIS FORM WITH THF I KCAL AGEriCY i!,iFLEMFNTiNG THE UNDERGROUND STORA • TANK REGULATIONS <br /> / //7 FOR0033A-R6 <br />