Laserfiche WebLink
e6OV" <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARDW 4a 9 ,�v <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �'t,•a„N`' <br /> MARK ONLY D 1 NEW PERMIT F::] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 11 4 AMENDED PERMIT [::] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA O %j&QArAMFCW NmfegPff ATiIr/ March Lane 76 <br /> AIM W. March <br /> wLane NEI-�aRr'A La® PARCEL#(OPTIONAL) <br /> Cn STATE TZ&IPCODE SITE PHONE#WITH AREA CODE <br /> CA207 208/473-7337 <br /> ✓ BOX A CORPORATION E�INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY F-1 COUNTY-AGENCY Q STATE-AGENCY' = FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS' <br /> If owner of UST Is a public agency complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR0 RESERVADDIAN is OF TANKS S E E.P.A. I.D.#(optional) <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS CAM82057432 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAft04!00W)REiarch Lane 76 PHONE E(LAST,FIRST) PHONE#WITH AREA CODE <br /> hMllxT6dAST/FI@�hch Lane 78 PHONE LU2l/4(3-/�3J/ NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ?MA[LgMR <br /> OPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> Products Company, LLC CARE OF ADDRESS INFORMATION <br /> T EET ✓[boxbIndicate = INDIVIDUAL = LOCAL-AGENCY 0 STATE-AGENCY <br /> U`CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITYJ4AME._ Men ST& ZIP COD52. PNQAI6�W4TH.A DE <br /> III. ANK OWNER INFORMATION•(MUST BE COMPLETED) (-� t/ t <br /> r Company, LLC CthIRiAWWW a' rROliance <br /> Q r STR DRESS I/ box bindicate = INDIVIDUAL 0 LOCAL-AGENCY = STATE-AGENCY <br /> r CORPORATION = PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> TY N M STATE ZIP CODE PHONE#WITH AREA CODE <br /> 1 t � CA 8 6y�7.7-, (714)572-7658 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 I e s arise. <br /> TY(TK) HQ 4 4-]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 2 GUARANTEE = 3 INSURANCE E�]4 SURETY BOND <br /> 0 5 LETTER OF CREDIT D 6 EXEMPTION E:1 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: I.a if.a III. <br /> THIS FORM HAS BEEN COMPLETED UNDER P ALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE M NTH/ AY/YY R <br /> wwol. A� '/7_1 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# _ —� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 4 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFOR Y. <br /> FORMA(3/93) <br /> OWNER MUST FILE THIS FOW THE LOCAL AGENCY IMPLEMENTING THE UNDERGR JWRAGE TANK REGULATIONS <br /> FOR0033A-R7 <br /> I <br />