Laserfiche WebLink
G6U'�-CRS <br /> STATE OF CALIFORNIA P• c_ <br /> STATE WATER RESOURCES CONTROL BOARD s, ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W <br /> ; <br /> CO LETE THIS FORM FOR EAcKoeuryisITE <br /> n <br /> MARK ONLY 1 NEW PERMIT RENEWAL PERMIT 5 CHANGE OF INFORMATION 77 7 PER ENTLY SEO SITE <br /> u <br /> ONE ITEM 77 2 INTERIM PERMIT 4 AMENDED PERMIT g TEMPORARY SITE CLOSURE !✓/ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) / <br /> DBA O A LITY NAME - i NA OF OPERATOR <br /> _" 7�t� <br /> A RES i /�/�/ ( NEAR�Mtklood <br /> TR ET I PARC'cL d(OPibNAlj <br /> kZ. L <br /> CITY NAME _� i STATE ` ZIP�40012 1 SITE PH E>6 WITH AREAi�E <br /> C i CA (�1iiIJ_..+� y S <br /> ✓ Box <br /> TO INDICATE 77 COR RATION 77 INDIVIDUAL PARTNERSHIP _7 LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY' FEDERAL-AGENCY <br /> DtSTRICTS <br /> YPE OF BUSINESSI GAS STATION (—• 2 DISTRIBUTOR —^ ✓ IF INDIAN a OFT T SITE E.P.A. 1.0.x(opnonaO <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: NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST.FIRS <br /> P #JILITH <br /> 11. PROPERTY OWNER INFORMATION- MU BE COMPLETED <br /> NAME CAREOF ADDRESS INFORMATION <br /> MAILI R TREET AO ESS ✓ box ainaicame _i INDIVIDUAL 'J LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP 1 COUNTY-AGENv Q FEDERAL-AGENCY <br /> CITY ME S74 ? HONE x WITH AREA Cf0)E <br /> 162?2 <br /> 310 <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME W R CARE OF ADDRESS INFORMATION <br /> MAIUN 'R STREET Ap9RESS• ty/'�� ✓ ddoaffxbcm J INDIVIDUAL LOCAL-AGENCY �_; STATE-AGENCY <br /> box / 9 =jg ( CORPORATION 77 PARTNERSHIP COUNTY-AGENCY a FEDERAL-AGENCY <br /> CITY NAM S: ZIP CE ® H p WITH AREA CODE <br /> C/ <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 I- �0 16T(l <br /> V. PETROLEUM UST FiNANCI PONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ box to indicate + SE LF-INSURED 2 GUARANTEE _ 1 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION L 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11' ecked. <br /> ^HECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L IL fW III. <br /> THIS FORK!HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APP4CAN T'S NAME ?q W TED 8 SIGNATURE) APPLICANTS TITLE DATE MONTWDAYiYEAR <br /> LOCAL AGENCY USE ONLY <br /> CCUNTY a i. ic. JURISDICTION a FACILITY a <br /> Av <br /> ...... ---A_OCATIC`" E J?rICNAL CZ:NSUS TRACT a -OPT: SUPViSCR-D+ TRIC"CCOE •CPTICNAL <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 /> A,, gn FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 6, ,"m 3 A.,'6 <br /> G, <br />