Laserfiche WebLink
1f <br /> • 60UR � <br /> STATE OF CALIFORNIA ,? <br /> 9 <br /> STATE WATER RESOURCES CONTROL BOARD 3 o <br /> r <br /> (TNEDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> p�(IPON N,� <br /> COMPLETE THIS FORM FOR EACH F YISITE <br /> MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT F__1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTO L) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA 5-236 c) = — <br /> I/ BOX <br /> TO INDICATE; CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR / IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> -( H v9-a -�s -4 ��� vau 3y <br /> PW 'TH AREA GODE <br /> NIGHTS: NAM (LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> SqPHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> N CORPORATION PARTNERSHIP COUNTY-AGENCY [] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 3? <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER 1 CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS `` -- ✓ box b indicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> LL,• O S P� e L.0 =CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> rn Yx �1S 3�L 3 7j- <br /> IV. <br /> SIV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if q stions arise. <br /> Nl <br /> 4 4 <br /> TY(TK) HQ - od � y® ��' <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE HODS) U �'�j(J`" L� <br /> ✓ box b indicate D I SELF-INSURED 2 GUARANTEE 3 INSURANCE =4 SURETY BOND <br /> 5 LETTER OF CREDIT UW6 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.❑ II.E III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODS- TIONAL CENSUS TRA CT OPTIONAL SUPVISOR-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 /> FORM A(5-91) <br /> FOR0033A-5 <br />