Laserfiche WebLink
rFS <br /> STATE OF CALIFORNIA • � °ti9 <br /> STATE WATER RESOURCES CONTROL BOARD a Lq. <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A CI <br /> 0 <br /> COMPLETE THIS FORM FOR EAC ACILITYISITE <br /> MARK ONLY <br /> NEW PERMII—_T 7 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM ?ERMIT x a AMENCED PERMIT 6 TEMPORARY SITE CLOSURE n C�� <br /> I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME QF OPERATOR <br /> ADDRESS / NEAREST CROSS STREET i PARCELO(OPTIONAL'i <br /> CITY NAME STAISO <br /> ZIPCODE, SITE PHONE a WITH AREA CODE <br /> CA <br /> ✓ BOX <br /> TO INDICATE �X CORPORAitON - 'SND,` AL _ PARTNERSHIP _ LOCAL-AGENCY COUNTY-AGENCY U STATE-AGENCY J FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS X I GAS STATCN 2 DIST;Ic'.,'OR _ ✓ IF INCIAN tt OF TANKS AT SITE E.P.A. I.D.x(optional) <br /> - RESERVATION <br /> FARM ^ <br /> 3 FAR - � 1 ?RL'CESSOR ��� 5 CT;�ER OR TRUST LANDS d � oo o a 133 3 8 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PH// 'CODE s "l;TH AREA SN,ODE DAYS: NAME(LAST,FIRST) <br /> _��rv�_l of N <br /> .- ( -)1t►t k�_-_- CS/ <br /> _ _9-.--$ 0 G PHONE I WITH AREA OO <br /> NIGHTS: NAME LAST.Fi-*_ST „v�FiC.c a.6 S-VV,,''-1 AREA.CODE NIGHTS: NAME tLAS T,FIRST) <br /> O /0 Q— Q PHONE a WITH APC4CO <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADD ✓ box ID indicate _ INDIVIDUAL C LOCAL-AGENCY STATE-AGENCY <br /> -/C�._JO 6�( ____s_7 - - __ _ .CORPORATION PARTNERSHIP C COUNTY-AGENCY C FEDERAL-AGENCY <br /> CITY NAME ` STATE ZIP CODE PHONE x WITH AREA CODE <br /> ►2 t M 6,YN-F- C 9ys3 9- 65 -g5_0 o <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER I 7CA7RECADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS v' box xinoicate INDIVIDUAL h LOCAL-AGENCY _; STATE-AGENCY <br /> XRPORATION PARTNERSHIP r_ COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE M WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> -, __ — <br /> TY(TK) HQ 4 4 - D j / -a I__7�3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate I SELF-INSURED _ 2 GUARANTEE3 INSURANCE 4 SURETY BOND <br /> 5 LETT ER OF CREDIT 6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal nctification 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.: II.X III.— I <br /> _J <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PE,4JURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME;P,1!,%-ED&SIGNATl1RE, APPLICANTS TITLE DATE MONTH,DAY,YEAR <br /> L CAL AGENCY USE LY <br /> CCUNTY# JURISDICTION# FACILITY# ,y� <br /> '_OCATION CODE P'!CNAL --%SUS";ACT tt -CP-,_`:,NAL S_-VISCR-DISTRICT CODE -OPTIONAL <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 /> ;.."I A;,z en FILE THIS FORM WITH THE LOCAL AGENCY T:IPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 0 <br /> FOR0031A-;6 <br />