Laserfiche WebLink
•c°,V. ,c <br /> STATE OF CALIFORNIA 4 `? <br /> • STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :�� u <br /> Cil IFUII N.� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM a 2 INTERIM PERMIT 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE Q, <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> D8 FACILITY NAyr+ENAME OF OPERATO <br /> A L U UZS O m r _ <br /> NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> "1 v <br /> LO J IL STAREA CODE <br /> TE A ZIP Sq9-5 � $IT�O�PHO� WITH A19dal <br /> I/ BOX C <br /> TO INDICATE Q CORPORATION XINDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Q 1 GAS STATION Q 2 DISTRIBUTORR SEIF R INDIAN #OF TANKS T ITE E.P.A. I.D.#(optional) <br /> Q 3 FARM Q 4 PROCESSOR 9 <br /> 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> PD YS: NAME(LAST,FIRST) PHONE WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NTOO— 2-o l) 30-1,9W. <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> c 6 C'R>r 1 <br /> MAILING OR STRE DDRESS ,///� ✓ box In indicate NDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> ♦ GZ r �N LtC/* Q CORPORATION 'Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CCODE <br /> IJY to ME/>I C STATA. ?&ZIP CODE 41. N ITH5,J <br /> 111.. TA((,,{{N�CC//K OWNER INFORMATION-(MUST BE COMPLETED) <br /> (! (►r>V) <br /> NA OF WR � CARE OF ADDRESS INFORMATION <br /> GIA <br /> MAILING OR STR�DDRESS T�o ^- ✓ box to indicate INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> IJ ! � CYJ Q CORPORATION Q PARTNERSHIP Q OUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME S TE' 7}f�CQ E ITH AREA t -/04 O <br /> 1 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-955-1 questions i <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM U T FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHODS) USED <br /> ✓ box to indicate 0 1 SELF-INSURED 0 2 GUARANTEE Q 3 INSURANCE 0 4 SURETY BOND <br /> R-A 0 5 LETTER OF CREDIT Q 6 EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or III is checked.ryItt <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.i1C 111. <br /> THIS FORM HAS BEEN COM ETED UNE NALTYIf ERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPIJCANS NAME(PRINTED&SIGNATU ) L� � <br /> PPLICANrS TITLE DATE ONTIDAIIEAR <br /> �hc � <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> mI I -I j g- / <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> CSL- Z3-9c, <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 /> FORM A(5-91) FOR0033A-5 <br /> i � <br />