Laserfiche WebLink
T7. f _7T - <br /> t60UN Cf <br /> STATE OF CAUFOR IA <br /> STATE WATER RESOURCES CONTROL BOARD W m�r 1e o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A os <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F-1t NEW PERMIT 3 RENEWAL PERMIT '5 CHANGE OF INFORMATION PERMANENTLYO <br /> ONE REM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSUR)<7 <br /> i" <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DRA OR FACILITY NAME NAME OF OPERATOR <br /> I. <br /> ADDRE5 , NEAREST CROSS STREET PARCEL#(OPrIONAL) <br /> f <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> CA <br /> ✓ BOX <br /> I TO INDICATE CORPORATION INDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY* E=l STATE-AGENCY' FEDERAL-AGENCY' <br /> - DISTRICTS' <br /> r 'N owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> Iy TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN J#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION J <br /> 3 FARM 4 PROCESSOR 0 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) PHONE i WITH AREA CODE <br /> 'i <br /> NIGHTS;NAME(LAST,FIRST) PHONE>f WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4TH AREA CODE <br /> II. RTYOWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATIOR <br /> MAILING OR STREET ADDRESS ✓ box to indicate [1:j INDIVIDUAL E::] LOCAL-AGENCY E�] STATE-AGENCY <br /> (�CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY <br /> i CITY NAME STATE ZIP CODE 7PHONE tl WITH AREA CODE <br /> III. TANK OWNER,INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER. CARE OFrE INFORMATION <br /> 4 ' MAILING OR STREETADOIR SS ✓box IDindic e INDIVIDUAL LOCAL-AGENCYSTATE-AGENCY ' <br /> 0 CORPORATION 0 PARTNERSHIP (]COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> r` <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBE -,C81L(916)322-9669 9 questions arise. <br /> H - - <br /> I TY(TK) • 4 4 <br /> V&.PETROLEUM UST-FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> boxbindcate 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 0 SURETY BOND <br /> D 5 LETTER OF CREDIT D 6 EXEMPTION ;a 99 OTHER <br /> �. <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: 1. 11.a III.O - <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST 0FMYXU16KEVGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION S FACILITY* <br /> LOCATION CODE•OPTIONAL CENSUS TRACT x -OPTIONAL SUPVISOR-Qj3T4ORWOPTIONAL <br /> • THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM Bs ANUNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> ( <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATUM <br /> FORMA(3193) g`� � FOR0033A-i7 <br /> 2i � <br />