Laserfiche WebLink
C60UN � <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ; .,--„ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A :� no <br /> o <br /> COMPLETE THIS FORM FOR EAC ACILITYISITE <br /> MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OFPERATO <br /> hC <br /> ADD ESS NE ST Rdl <br /> CROSS TREET PARCEL#(OPTIONAL) <br /> iV11011 <br /> CITY NAM STATE ZIP C E SITE PHON #WITH AREA CODE <br /> ��-fo G CA <br /> ✓ Box <br /> TO INDICATE CORPORATION INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY (]COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANK AT SITE E.P.A. 1.D.#(optional) <br /> IF <br /> 0 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAS FIRSPHONE#WI)AREA CODE DAYS: NAME(LAST,FIRST) <br /> t'k4'4 �, " c�Qq E <br /> PHONE <br /> NIGHTS: NXME rLAST,FIRA PHONE#WI AEA tODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box toindicate INDIVIDUAL Q LOCAL-AGENCY <br /> STATE-AGENCY <br /> Q CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST B COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box loindicateINDIVIDUAL <br /> Q � LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b Indicate 0 1 SELF-INSURED rLD 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> E__1 5 LETTER OF CREDIT =6 EXEMPTION 0 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: 1.[::] it.[::] III.a <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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OP ONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> -3 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONO. <br /> FORMA(5-91) -7— 13-7 p>^ q✓1] F <br />