Laserfiche WebLink
• • boua e <br /> STATE OFCAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITXX! <br /> NAM `` NAME OF OPERATOR <br /> f ! A& cSJ (a IV U^NJ(-ij QS A'C it ijn5.7 td,G <br /> ADDRESS ✓j NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> CIN NAME STATE ZIP CODE SITE PHONES WITH AREA CODE <br /> BOX ►�'�-� ca 9' 3 �o - ,?j <br /> T NDICATE CORPORATION INDIVIDUALPARTNERSHIP Q LOCAL-AGENCY 0 COUNTY-AGENCY' (]STATE-AGENCYFEDERAL-AGENCY' <br /> DISTRICTS' / }p <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 1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN IS OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> p� RESERVATION 3 <br /> 0 3 FARM Q 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME LA I,FIR T) PHONE�WITH AREA RE CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> p �,J o <br /> L#16 Y1>rN� `Loq <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> a -10 27-NI? <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> C°N�>LocL� �}tN,VrJj)4+-� L��.' AL1, <br /> MAILING OR STREET ADDRESS ^ ✓box IDitdicate ED INDIVIDUAL E:1 LOCAL-AGENCY Q STATE-AGENCY <br /> 3 33 6 81"S� AV d' Z O Q CORPORATION = PARTNERSHIP Q COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 601V U CIA1 1644 M &(IvQQ 0-,d L L G X LL e- <br /> MAILING OR STREET ADDR nnSS^^��, ✓box b Indicate INDIVIDUAL = LOCAL-AGENCY (]STATE-AGENCY <br /> 3),? t�• APV ZYl7 =CORPORATION (] PARTNERSHIP =COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE#WITH ARE ,06DE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4--F4--]- <br /> V. <br /> 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bIndicate 0 1 SELF-INSURED Q 2 GUARANTEE [] 3 INSURANCE <br /> 5 LETTER OF CREDIT 6 EXEMPTION 99 OTHER O 4 SURETY BOND <br /> O <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.E] III. <br /> THIS FOYM HAf BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NANT SIGNED) OWNER'S TITLE GATE MONTWDAY/YEAR <br /> P cs)-A>l7' <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m 0,11151 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL SUPVISOR-DISTRICT CODE -t?PIpNAt <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMITAPPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE T 7�7 <br /> FORMA(3193) <br /> FOi10003A-R7 <br />