Laserfiche WebLink
STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EACH FACIL(TYISITE <br />MARK ONLY F-1 i NEW PERMIT F-1 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION V7 PERMANENTLY CLOSED <br />ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBAO CILITy M NAME ,\YA /I� <br />NAME OF OPERJOfl <br />ADDR W. - - <br />je <br />NECW CRLT$ flEE <br />•L�(JR NV �r <br />P ELN(OFfpNAL) <br />CITY NA <br />STATE <br />ZIPCW4z / <br />SI PHONE WITH AREA CO <br />CA <br />S <br />r/!i <br />I/ BOX <br />TO INDICATE D CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL -AGENCY COUNTY -AGENCY O STATE AGENCY 0 FEDERALAGENCY <br />DISTRICTS <br />TYPE OF BUSINESS O 3 GAS STATION Q 2 DISTRIBUTOR <br />0 '/IF INDIAN <br />NOF TA AT SITE <br />E.P.A. I. D. N (aph'ana/) <br />0 3 FARM Q 4 PROCESSOR 0 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON [SECONDARY) • optional <br />DAYS: NAME (LAST, FIRST) <br />PHONE N WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) PHONE a WITH AREA MDF <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE N WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ E bhftab 0 INDIVIDUAL 0 LOCAL -AGENCY 0 STATE -AGENCY <br />a CORPORATION Q PARTNERSHIP O COUNTY -AGENCY 0 FEDERALAGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE N WITH AREA CODE <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />OoxblMbab 0 INDIVIDUAL 0 LOCAL -AGENCY STATE AGENCY <br />0 CORPORATION 0 PARTNERSHIP COUNTY -AGENCY 0 FEDEMLAGENCY <br />CIN NAME <br />STATE <br />ZIP CODE <br />PHONE N WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323.9555 it questions arise. <br />TY (TK) HQ 4 4 - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMP D) - IDENTIFY THE METHOD(S) USED <br />✓ bo�bindkab I� 1 SELF-INSURED 0 2 ARANTEE E-1 3 INSURANCE 0 4 SURETY SONO <br />D 5 LETTER OF CREDIT EXEMPTION M W 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 />LUUAL AGtNUY U5E ONLY <br />COUNTY N Lawes Nr JURISDICTION N <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION <br />FORM A (5-91) <br />`✓ <br />FACILITY M <br />-q v; <br />UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />OTIOW3A-5/ <br />