Laserfiche WebLink
-i'JVR .S Com. <br /> + STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> C/ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORS' A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ I N RMIT II 3 RENEWAL PERMIT El 5 CHANGE OF INFORMATION 7 T CLOSED SITE <br /> CME ITEM 2 INTERIM PERMIT C 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE tJ 2 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME Q NAME OF OPERATOR <br /> 1 / <br /> ADDRESS NEAREST CROSS STREET PARC Ll <br /> CITY NAIAE I STATE ZIP CODE SITE PHONE aTH AREA CODE <br /> TO DIICC,ATE Q CORPORATION INOIVIOUAL 1 PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY [1 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTORQ ✓ IF INDIAN x OF TANKS AT SITE E.P.A. 1.D.A(optional) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: E(LAST,FIRST) PHONE a WITH AREA CODE D NAME(LAST,FIRST) ? r— <br /> NIGHTS: NAME(LAST,FIRST). PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FI ST) <br /> eLAONIr eWITH AREA <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> N IAE ` � � � CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADORES�S f ✓box indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY'-,, <br /> o CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> qIlI. <br /> I ME STATE ZIP CODE PHONE a WITH AREA CODE <br /> e <br /> . OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWN CARE OF ADDRESS INFORMATION <br /> MAILING 0q(/(/„3T EET ADDRESS ./ �x a =y -' <br /> INDIVIDUAL Q LOCAL-AGENCY Q STA7EAGENCY; <br /> r✓e A Aer CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CIN NAME � Lr� �STATE ZIP CODE �/ PHONE x WITH E ODE <br /> 00 <br /> V BOARD OF EQUALIZATION UST STOR GE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F474 ,'_1 - - - - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓dos»indicate Lam_ I SELF-INSURED IQ 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BONG <br /> D 5 LETTEROFCREDIT 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 II is checked. <br /> CHECK ONE BOX INDICATING WHICH A80VE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPL;CANT'S NAME(PRINTEED 6 SIGNATURE) APPLICANTS TITLE DATE MONTWOAYNEAR <br /> i — J� <br /> LOCAL AGENCY USE ONLY W <br /> COUNTY# JURISDICTION# FACILITY# <br /> ,wI <br /> 0$1 L '7 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL (SUPVISOR•DISTRI T CODE -OPTIONAL <br /> Z .(7J <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) FCR0033A-5 <br />