Laserfiche WebLink
'e6oUR e C <br /> STATE OF CALIFORNIA <br /> P <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA w " ° <br /> ff✓��////"'/// COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY 1 NEW PERMIT F—] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT [::] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILI NAME NAME OF OPERATOR <br /> >� " fart/ ✓.4'r/uc✓ <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE ITE PHONE#WITH AREA CODE <br /> G CA y"23 Zai)72,7--13 <br /> ✓ BOX <br /> TOINDICATE O CORPORATION INDIVIDUAL D PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY (] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM a 4 PROCESSOR OTHER OR TRUST LANDS 2— <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NALAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> all*?, <br /> TR - )7L7-�5_vy <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> :zY, PHONE#WITH AREA CODE <br /> - <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> /v <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL = LOCAL-AGENCY STATE-AGENCY <br /> Al- `� <� All) CORPORATION PARTNERSHIP = COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STA-T�/ ZIP CODg ONF,#WITH AREA CODE <br /> Ud" Z J 727 -53/ <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAIA [S <br /> LING OR STREET ADPRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY TATE-AGENCY <br /> !j•It7v/ _ lj�i �� /� CORPORATION PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY f,G��_ O� STATE ZIP CODE � PHONE, -72—WITH 7 A C � <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323--9555 if questions arise. <br /> TY(TK) HQ 4 4 - 2-161 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1� 1 SELF-INSURED 0 2 GUARANTEE = 3A SURANCE 4 SURETY BOND <br /> O 5 LETTER OF CREDIT 0 6 EXEMPTION LV99 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: I.❑ 11.0 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) APPLICANT'S TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> [��l � LIZ 1/17, v sliU-�,nIV 2 ! <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL �- y1j1q( <br /> THIS F RM MUST BE ACCOMPANIED BY AT`3LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0033A-5 <br /> r �j� <br />