Laserfiche WebLink
i 0 `$ <br /> STATE OF CALIFORNIA ...... <br /> , <br /> w <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A y(e <br /> 4i <br /> c 'jy. <br /> • SCI-DA M� <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 0 <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMEt I ME OF OPERATOR <br /> !yMly <br /> ADDRESS NEAREST CROSS STREET PARCEL t(OPTIONAL) <br /> LIZ;iii/ C1,16 <br /> CITY NAME I STACA ZIP COOS � SITE PHONE t WITH AREA COO <br /> 94� <br /> ✓ BOX Y7,TO INDICATE ORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY <br /> DISTRICTS L� STATE-AGENCY Q FEDERAL AGENCY <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR = ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.0.A(optional) <br /> 4 PROCESSOR RESERVATION <br /> Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) __ EMERGENCY CONTACT PERSON (SECONDARY)-optional `" <br /> DAYS: NAME LAST,FIRST) PHONE t WITH AREA CODE DAYS:NAME(LAST,FIRST) <br /> IGHTS: NAME LAST. IRST) PHONE t WI H AREA CODE NIGHTS: NAME(LAST, R <br /> PHONE s WITH AREA CnnF; <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPL <br /> NAME CARE OF ADDRESS INFORMATION <br /> MALING OR ST E D <br /> I DRESS ( � ✓hos biMicata <br /> CORPORATION Q INDIVIDUAL Q LOCAL-AGENCY (Q STATE-AGENCY <br /> Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME �-. D STATE ZIP COpE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER 3 CARE OF ADORESS INFORMATION <br /> — <br /> MAILING OR STREET ADDRESS ✓ bmmemI <br /> Q INDIVIDUAL Q LOCAL-AGENCY Q STATE•AGENCY <br /> CITY NAME Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> STATE LP CODE PHONE s WITH AREA CODE <br /> IV.BOARD OF QUALIZATION UST STORAGE FEE ACCOUNT NU BER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - 6 <br /> V. PETROL UM UST FINANCIAL RESPONSIBILITY-(MUST SE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> F�7b <br /> irbkaM Q 1 SELF•INSURED �IG.U~EE <br /> O S PTION a 3 E a t SURETY BOND <br /> OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 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 BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED d SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> w <br /> COUNTY# 'ZfZ JURISDICTION# FACILITY# <br /> vv <br /> LOCATION CODE •OPTIONAL CENSUS QCT s-QPT1pMAL SUPVISOR-DISTRICT CODE •OPTIONAL <br /> C.31/0 O <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A rH_ OF RE INFORMATI ONLY <br /> FORM A(5.91) <br />