Laserfiche WebLink
e <br /> C6�IJN � <br /> ' � IYIIRR C <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARDF 4a S <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `4 FERN`' <br /> MARK ONLY t NEW PERMIT 0 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION [�] 7 PERMANENTLY C <br /> ONE REM [::] 2 INTERIM PERMIT I _� 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ) <br /> DBA OR FACILITY NAM � /V NAME OF OPERATOR <br /> / kh%-AJ <br /> ADDRESS NEAR STCROSS1 ©REET PARCEL NPfIONAL)/30—�� <br /> fWftm_A9_ 51 <br /> CITY NAME STATE ZIP COD SITE PHONE#WITH AREA CODE <br /> G1GT�ic/ CA x?4 & 209 11P$ �7 <br /> `/ BOX <br /> TO INDICATE CORPORATION LOCAL-AGENCY INDIVIDUAL O PARTNERSHIP DISTRICTS' COUNTY-AGENCY E=1STATE•AGENCY' OFEDERAL-AGENCY' <br /> If owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS i GAS STATION 0 2 DISTRIBUTOR 0 RESER INDIAN #OF TANKS AT SITE E.P.A. I.Dom�#(o^^ptioon^nal) C <br /> 0 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDSI C- 0 0 1300 J00 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) P ONE#YVITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> s 41W <br /> NIGHTS:.biAME(LAST,F FIST) HOVE#WITH AREACODENIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAMECARE OF&ODRESS INFORMATION <br /> .R s— <br /> MAILING OR STREET ADDRESS ✓ hox to indicate IVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> �r (]CORPORATION 0 PARTNERSHIP (]COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP D� PHONE#WITH AR CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDR SS INFORMATION <br /> �AIZ#07LI <br /> MAILING�OR^STREET ADDRESS ✓ box bindicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> !ti -"zt'� 0 CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME �>�7N STATE - ZIP CjO— 4)� - A WITH#4A _ <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. ((�O� <br /> TY(TK)(�o 4T4 1-1 O 13 1 on I o 3_1�1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 0 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> 5 LETTER OF CREDIT 0 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 II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ Il. III. <br /> THIS FORM HAS B7 COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINAy� <br /> NED) OWNER'S TITLE �/ DATE MONTWDAY/YEAR <br /> LOCAL AGEN&USE ONLY <br /> COUNTY# JURISDICTION# FACILITY 00�jj <br /> m a3&1 ao 1& 14 10 1&1 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT OPTIONAL <br /> C? to 2$ c'b <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE NFORMATIO ONLY. <br /> OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO �STORAGE TANK REGU <br /> J�` FORM A(3193) ,t- /� ' /vIe 7 FOR=3A-R7 <br />