Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3 l <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> •C-l,«G1N N- <br /> COMPLETE THIS FORM F EACH F LIfY/SITE <br /> MARK ONLY � T'-�-� RENEWAL PERMIT RANGE OF INFORMATION 7 PERMANENTLY CLOSED <br /> ONE ITEM,-'`rte, 2 INTERIM PERMIT �`4 AMENDEO•RE MIT 6"TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FAC iTY NAME NAME Of PE BATOR - <br /> nt-r l Ndeg- 51nH <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAMESTATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> jbA S'"3 7G -�3Z-- <br /> ✓ Box --e_ <br /> TO INDICATE Q CORPORAT-b)t"-Q INDIVIDUAL Q P4ITNERSI4P - l Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY'/ <br /> TYPE OF BUSINESS Z-11"GAS STATION 2 OtSTRIBU70R ® ✓ IF INDUIN s OF TANKS AT ITE E.P."A L D a�iptionap <br /> s RESERVATI <br /> Q 3 FARM ® 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> ,----EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional � <br /> DAYS; N f(LAST,FIRST) PHONE s WITH Ak0pREA CODEDAYS: NAME(LAST.FIRS _ 7 O�g <br /> NIGHTS: NAME(LAST,F ST) PHONE#WITH AREA CODE NIGHTS:NAME(LAST IRST) <br /> EHONE t\ — s WITH AREA <br /> 11. PROP REOP TY-WNEh-INPORMAT10N- MUST BE-COMPLETED NAME." 4 CARE OF ADDRESS INFORMAT N <br /> 51 <br /> MAILING OR STREET ADDRESS ✓ box b Roam Q INDIVIDUALQ LOCA CY <br /> STATE-AY <br /> p� Q Q <br /> V CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WIJH 6REA CODE <br /> 73 . 122 6, -X36/5- <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNERa CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS rp+) ✓ Wx ID <br /> s� ` , (NDIVOUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> ? 3 l i t �-I rj' (J ®CORPORATION Q PARTNERSHIP Q COUNTY.AGEN CY Q FEDERAL-AGENCY <br /> CITY NAME --m� _.� __._.. STATE ZIP CODE PHONE#WITH AREA CODE <br /> 1- <br /> 4 S-;3 <br /> IV.BOARD OF EQUALIZATION UST_STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 44 - m <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box Mcate Q 1 SELF-INSURED .I 2 GUARANTEE Q 3 INSU E Q 4 SURETY X40 <br /> Q 5 LETTER OF CREDIT Q 6 EXEMPTION 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: 1. IL Ili. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> r <br /> LICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> L/- /3 - Z <br /> LOCAL AGENCY USE ONLY <br /> C(OU�NTY�# JURISDICTION# FACILITY# <br /> A101-F4 J C/ <br /> LOCATION CODE TIONAL CENSUS TRACY# •OPTrONAt SUPVISOR•OtSTRK:T CODE •OPTIONAL <br /> Z.. <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) 0 FOR0033A-5 <br />