Laserfiche WebLink
STATE OF CALIFORNIA -- <br /> 02 WATER RESOURCES CONTROL BOARD <br /> r 41NDERGROUND STORAGE TANK PERMIT APPLICATION • FORS I A <br /> COMPLETE THIS FORM FOR EAC ACILITYISRE <br /> MARK ONLY I_1 I NEW PERMIT r'I 9 RENEWAL PERMIT <br /> �J 5 CHANGE OF INFORMATION 7 P Y CLOSED S <br /> ClIE ITEM 1-1 2 INTERIM PERMIT s AMENDED PERMIT ; I 8 TEMPORARY SITE CLOSURE 7" <br /> I. FACILITYiSITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> 03A;,R.AGILITY NAME i NAME OF OPERATOR <br /> ACCRESS r - NEAREST CROSS STREET I PARCEL+(CPTIONAL) <br /> CITY NA AE ( STATE I ZIP CO E SITE PHONE s WITH AREA CODE <br /> I/ aox .CA :7 <br /> TINDICATE Q CORPORATION Q I IOUAL I_'PARTNEASHIP 1_LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DlsralcTs <br /> TYPE OF 3USINESS i� I GAS STATION !_: 2 OISTRGUTOR Q ✓ IF INDIAN s OF TANKS AT SITE F.P.A. L 0.s(apnonaq <br /> IF <br /> 4`_1 ] FARMr ii s PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE NIGHTS:NAME(LAST.FIRST) <br /> ouC c a RcA CCr1c <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME I CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa a wacaa Q INDIVIDUAL Q LOCAL•AGcNCY Q STATE-AGENCY <br /> j Q CORPORATION Q PARTNERSWP Q COMNTY•AGENCY Q F20VAL-AGENCY <br /> CITY NAME ( STATE { ZIP CODE i PHONE s WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> ,o\/ - <br /> MAILING OR STREET ADDRESS ✓ bs amcm <br /> 1`71 INDIVIDUAL INDIVIDUAL , LOCAL•AGENCY Q STATE-AGENCY <br /> Q CORPORATION = PARTNERSWP Q)COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAMEA A ,"'t Q /v I SraTE A I Zw CODE . PHONE R WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if qtfstions adie.' <br /> TY(TK) HQ F47741-1 d 3111 , <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓box bmicys Q I SELF-INSURED Q 2 GUARANTEE Q S INSURANCE Q t SURETY aOND <br /> Q S LETTER OF CREDIT Q 6 EXEWMON Q N OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L IL= NL u <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONTWDAYYYEAR <br /> LOCAL AGENCY USE ONLY <br /> CO'r7"rt JURlSOICTION x FACILRY p <br /> E" <br /> LOCATION COOS - TIONALLI CENSUS TRACT s •OPTIONALe3 L,!Z -SUPVISOR ISTRCT CODE -OPTIONAL <br /> /✓) r <br /> THIS FCRM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT A PLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(5.9I) FClt0015A•5 <br />