Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3 4�; 90 <br /> UNDERGROUNDSTORAGE TAN I APPLICATION - �� ! o, <br /> pr COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> E <br /> RK ONLY � 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITNE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE OPLETD) , <br /> DBAOR FACILITY NAME 1 G M NAMEOF ERATOR <br /> Z� <br /> p Il <br /> ADDRESS ��'@' (,, �l!_e. NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 0 1�i 6 �i W &JO <br /> CITY NAME STATE' ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓ BOX <br /> TO INDICATE COR =-PARTNEASF(IP 0 LOCAL-AGENCY COUNTY-AGENCY [] STATE-AGENCY (� FEDERAL-AGENCY <br /> _INDIVIDUAL- DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTORO R I/ IFSERVATION #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: N PHONE#WITH AREA CODE DAYS: t�,AME(LAST,FIRST) s �-� <br /> Z� -A Cy", <br /> NIGHTS: NAME(LAST,FIRST) PHONEY#WI E OE NI HTS: NA (LAST,FIR <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to Indicate 0 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION PARTNERSHIP [] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> / ofe X / CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE /) PHONE#WITH ARZtE <br /> I/ <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(T ) 4 4 -1 1 1 1 <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 []4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or it is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[�] II.0 ill. <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&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# ITS' <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# - TIONAL SUP ISOR-DISTRICT CO OPTIONAL <br /> THIS FORM MUST BE ACCOMPANI Y- EAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOROMM-5 <br />