Laserfiche WebLink
�"Ou ces <br />IV STATE OF CALIFORNIA ? P c° <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a��- o <br />COMPLETE THIS FORM FOR EA ACILITY/SITE <br />MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT EK 5 CHANGE OF INFORMATION [_] 7 PERMANENTLY CLOSED SITE <br />ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT El 6 TEMPORARY SITE CLOSURE n <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />CARE OF ADDRESS INFORMATION <br />NAME OF OPERATOR <br />Lt LTaA2� <br />ss zW, a, C 4 4., <br />✓ box to indicate �lIODIVIDUAL <br />Ca 1v< --2r <br />ADDRESS <br />/52 i-/ <br />G_/? F51VU A-116% <br />CORPORATION 0 PARTNERSHIP <br />NEAREST CROSS ST EET <br />Ck11919 76;�C <br />PARCEL #(OPTION L) <br />CITY NAME <br />ZG' G/<-- L-di✓C .� Gl S Z�' <br />STAT <br />CE <br />STATE <br />CA <br />ZIP CODE <br />g Z'47�o <br />SITE PHONE # WITH AREA CODE <br />.70q -1I 33— /S2 <br />✓ BOX <br />TO INDICATE <br />0 INDIVIDUAL = PARTNERSHIP <br />0 LOCAL -AGENCY COUNTY -AGENCY 0 STATE -AGENCY 0 FEDERAL -AGENCY <br />-CQpPORATION <br />LLLLL.����c <br />DISTRICTS <br />[TYPE OF BUSINESS <br />1 GAS STATION 2 DISTRIBUTOR/ <br />IF INDIAN <br />RESERVATION <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />0 3 FARM 4 PROCESSOR = <br />5 OTHER <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET A RESS✓ <br />_ <br />MAILING ORSTREET AADD'DRESS <br />✓ box to indicate �lIODIVIDUAL <br />� LOCAL -AGENCY 0 STATE -AGENCY <br />8 7 (/ <br />���% <br />CORPORATION 0 PARTNERSHIP <br />COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />oC <br />2�A✓' <br />STAT <br />CE <br />ZIP ODE <br />5-2/2— <br />PHONE # WITH AREA CODE <br />20el,- - <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OFFCO/WNNER <br />CARE OF ADDRESS INFORMATION <br />DATE MONTH/DAY <br />MAILING OR STREET A RESS✓ <br />_ <br />box to indicate (] INDIVIDUAL <br />[� (( __ <br />0 LOCAL -AGENCY 0 STATE -AGENCY <br />W C <br />CORPO67M 0 PARTNERSHIP <br />0 COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITY NAME J <br />STATE <br />ZIP CO <br />PHONWITH AREA COD1:11/1S /7 f <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />TY (TK) HQ F4]4]_ 3 - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to indicate 0 1 SELF-INSURED 2 GUARANTEE �*3 INSURANCE 0 4 SURETY BOND <br />L-1 5 LETTER OF CREDIT 6 EXEMPTION L-1 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: I. E II. 1--] 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 & SIGNATURE) <br />APPLICANT'S TITLE <br />DATE MONTH/DAY <br />n� <br />YEAR <br />LOCAL AGFNCY IISF ONLY <br />COUNTY # JURISDICTION # FACILITY # <br />m Fm 1�1 <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 />