Laserfiche WebLink
b <br /> � Peb°ure es� <br /> STATE OF CALIFORNIA P• ° <br /> STATE WATER RESOURCES CONTROL BOARD a , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A d �e <br /> •C�(IFOR N.r <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY D 1 NEW PERMIT 3 RENEWAL PERMIT K5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS <br /> ONE ITEM a 2 INTERIM PERMIT 0 4 AMENDED PERMIT D 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME OP AT R <br /> Cert" .e Gf10I rk / N OFazw <br /> ADDRESS161 D ` � a O <br /> CITq NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> O G `t&� CA <br /> ✓ BOX <br /> TOINDICATE CORPORATION (]INDIVIDUAL = PARTNERSHIP 0 LOCAL-AGENCY (]COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR ,/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: N ME(LAST,FIRST) PHONE#WITH AREA CODE DA S: NAME(LAST,FIRS <br /> r RHONE;9 WITH ARPA mm: <br /> NIGHTS: NAME(LAST,FIRS PHONE#WITH AREA CODE NI TS: NAME(LAST FIRST) <br /> PHONE#WITH AREA CODF <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 <br /> 0 STATE-AGENCY <br /> 0 CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OFOWNE .x ^N) CC O CARE OF DRS INFO R`ATION 14 r <br /> MAILING R REET ADDRESS l/� ✓ box Fo ndicato '"� INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> r t =CORPORATION PARTNERSHIP (]COUNTY-AGENCY FEDERAL-AGENCY <br /> CI NAME STATE 21P C DE PHONE#WITH AREA CODE <br /> T4 I <br /> IV. BOA D.OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate = 1 SELF-INSURED 0 2 GUARANTEE 03 NSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION [9 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: 1.0 II. 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 MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY C <br /> COUNTY# JURISDICTION# FACILITY# <br /> Z <br /> F <br /> ol <br /> LOCATIONE - PTIONAL CE US TRACT# -OPTIONAL SU VISOR-DISTRICT <br /> �OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIE 1 OR MOR IT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0033A.5 <br />