Laserfiche WebLink
'esoua es <br />• STATE OF CALIFORMA .,� o <br />s <br />STATE WATER RESOURCES CONTROL BOARD s �� .� o <br />^ 1 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e <br />°4noe M`� <br />COMPLETE THIS FORM FOR EACH FACILITYISITE <br />MARK\0V&/ I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br />ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE /Q> <br />I CAT4I ITVIQITF IMFORMATInKI R AnnRFS(; - IMIIST RE COMPLETED) <br />DBA OR FACILITY NAME <br />DAYS: NAME (LAST, FIRST) PHONE #WITH AREA CODE <br />O <br />./�s u� X09 599 Ps <br />NAME OF 0;5ATOR <br />NIGHTS: NAME (LAST-, FIRST) PHONE#WITH AREA CODE <br />..NAME <br />✓ �xblMkab DIVIDUAL <br />LOCAL -AGENCY STATE -AGENCY <br />-;zz *0 <br />ADDRESS <br />COUNTY -AGENCY FEDERAL -AGENCY <br />STATE <br />CR <br />NEARE�YCIROSS SJREET S� <br />PARCEL#(OPfIONAL) <br />PHONE # WITH AREA CODE <br />av I S I - 7I <br />STATE <br />ZIP CODE <br />PHONEI WITH AREA CODE <br />CITY NAME <br />03 <br />STATE <br />ZIP E <br />S36G <br />SITE PHONE WITH AREA CODE <br />CA <br />99a39/f <br />✓ BOX <br />TO INDICATE O CORPORATION O INDIVIDUAL PARTNERSHIP <br />0 LO NCY 0 COUNTY -AGENCY STATE -AGENCY 0 FEDERAL -AGENCY <br />DISTRICTSTRICTSTRICTS <br />TYPE OF BUSINESS <br />GAS STATION 0 2 DISTRIBUTOR0 <br />✓ IF INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. %(optimal) <br />0 <br />3 FARM 0 4 PROCESSOR <br />O5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />3 <br />EMERGENCY WNTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) • optional <br />DAYS: NAME (LAST, FIRS�T)PHONE #WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) PHONE #WITH AREA CODE <br />/io/SE�J ae Po O 'S iYDS <br />./�s u� X09 599 Ps <br />NIGHTS: NAME (LAST, FIRST) PHONE #WITH AREA CODE <br />NIGHTS: NAME (LAST-, FIRST) PHONE#WITH AREA CODE <br />MAILING OR STREET ADDRESS <br />✓ �xblMkab DIVIDUAL <br />II DDnDCOTV nWMCD INFTIRMATIOM .IMI ICT RF rOMPI FTFm <br />E <br />CARE OF ADDRESS INFORMATION <br />CARE OF ADDRESS INFORMATION <br />St1 <br />e ro t <br />MAILING OR STREET ADDRESS <br />✓ �xblMkab DIVIDUAL <br />LOCAL -AGENCY STATE -AGENCY <br />-;zz *0 <br />0 CORPORATION 0 PARTNERSHIP <br />COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />- OY'\— <br />STATE <br />CR <br />ZIP CODE <br />s 310 6 <br />O COUNTYAGENCY 0 FEDERAL -AGENCY <br />PHONE # WITH AREA CODE <br />av I S I - 7I <br />III TAMK nWMPR INF(1RMATION. (MIIST RF mmpi FTFD) <br />NAME OF OW NER <br />CARE OF ADDRESS INFORMATION <br />e ro t <br />MAILING OR STREET ADDRESS <br />v INK bimW OINDIVIDUAL <br />DLOCAL-AGENCY OSTATE-AGENCY <br />O ov-v� S W, <br />��11 <br />Sod <br />CORPORATION O PARTNERSHIP <br />O COUNTYAGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONEI WITH AREA CODE <br />03 <br />113 — I I I <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 739-2582 if questions arise. <br />TY (TK) HQ [4-P4 - 0 Z- 0 3 1 31 <br />V. 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.[—] II.L] III. Ef/ <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANTS NAME(PRINTED& SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # FACILITY # <br />15-11 o SZ- AA-NL#5e 22 <br />LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR- DISTRICT CODE -OPTIONAL <br />S 3 3 - zs—S0 2Z <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 />FOR0033A R2 <br />FORMA (9-90) <br />