Laserfiche WebLink
STATE OF CALIFORNIA �P P •� cO. <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATI - FORM A w - <br /> �6 -n <br /> •C4lIfOH N`r <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 0 1 NEW PERMIT F__] 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED <br /> ONE ITEM F—] 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FAC �/ NAME ,OPEROR j I f 0 <br /> VA <br /> ADDRE S NEAR T CROSS STREET PARCEL#(OPTIO rAL) <br /> zovo rrrn mJ <br /> CIN NAME � �` STACEA ZODEA SITE PHONE#WITH AREA CODE <br /> ✓ BOX /V /// ++ <br /> TO INDICATE l�CORPORATION l7 INDIVIDUAL PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> g .. RESERVATION <br /> 3 FARM F 4 PROCESSOR OTHER OR TRUST LANDS 41 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIR PHONE#WITH AREA CODE DAYS ME(LAST,FIRST) -�`, <br /> •� . + t,t .7" • 2 q, �3-533 :aAr 4 `7J7 J <br /> NIGHTS:j'AME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS ME(LAST,FIRST) r <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME" � ! / CARE OF ADDRESS INFORMATION <br /> ., ' C�t L i� /vim/•.$l:t�'� U�a'LU <br /> MAILING OR STREET ADDRESS ✓ box to indicate = INDIVIDUAL LOCAL4GEN STATE-AGENCY ° <br /> P C) ��,,� it JJ//�� G/+ Q CORPORATION =G[PARTNERSHIP (� COUNTY--AGENC __Q FEDERAL-AGENCY <br /> AREA <br /> CITY NAME L ° t �✓Pf �J' STtA. ZI zC'JWITH <br /> r`lrCODE <br /> 7 p t� <br /> III. T1AAN:K�c � fVY.Ir <br /> OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME �0CARE OF ADDRESS INFORMATION i <br /> CANE AJA 1,)iVWJ 4&AaO <br /> MAI OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL (] LOCAL-AGENCY TATE-AGENCY <br /> 'z.(,<1 Q CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAn C Sm . ZIP coDPHONE#�ft71TH AREe. ..., <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. OQ' <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 0 1 SELF-INSURED E�:]2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT 0 6 EXEMPTION 0 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. II.O III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) ICAN,S T LE DATE MONTHlDAYNEAR <br /> APPL <br /> _r,Wvr114 <br /> aAt�z <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 7; <br /> j © 3x' <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 />