Laserfiche WebLink
• e$OUR e3 <br /> STATE OF CALIFORNIA Ae P " ori <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A a40 <br /> s 0� 0 <br /> •C�[1FOR N� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY EPfl NEW PERMIT F_� 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SIT <br /> ONE ITEM F__] 2 INTERIM PERMIT F__1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 'Ilk <br /> DBA OR FACILITY NAME NAME OF OP RATOR <br /> wigs,=- --r-�C � rn — �� ua� �—+ �� , �� <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE CODE SITE PHONE#WITH AREA CODE <br /> L CON CAI/ BOX <br /> TOINDICATE CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY ED COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS J?5_1 GAS STATION O 2 DISTRIBUTOR ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION q <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS �3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> m(a09-c— G.,k" `3 — 9 <br /> —M 0 PHONE#WITH AREA com <br /> NIGHTS: NAME(LAST,FIRST) / P ON 3 "-#WITH AREEAA�C015E NIGHTS: NAME(LAST,FIRST) <br /> mco Pe, G\\L 4 el 1 0 4� lCq PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bo to indicate E:j INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION I] PARTNERSHIP E�j COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE: AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> AQEOFOCARE F ADDRESS INFORMATIONN -� �i" ` � W -- <br /> MALING OR STREET A DRESS ✓ bo toindicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> i .� CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY <br /> ��NAME <br /> pp STTAA*TEZIP 90DE P OyNE/# IT AREA CODE <br /> (tqIV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4]-4]-10 1'�?I�-I_01& <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THEM THOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 2 GUARANTEEINSURANCE 4 SURETY BOND <br /> 5 LETTEROFCREDIT 6 EXEMPTION 799 OTHER N0 <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. III.❑ <br /> THIS FORM HAS BEEN COMPLETED U ER PEATY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATUR APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> Nk AlzC4, WE- MIGhL <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 7/L 0 <br /> m D16 10 1 U <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -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) FOR0033A-5 <br />