Laserfiche WebLink
QZJJR t <br /> STATE OF CALIFORNIA ,�' ^e <br /> STATE WATER RESOURCES CONTROL BOARD s`,�,� �s <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A � o; <br /> C�tlfO„M,� <br /> COMPLETE THIS FORM FOR EACH F /SITE <br /> MARK ONLY Q 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SffE <br /> ONE REM Q 2 INTERIM PERMIT d AMENDED PERMIT F1 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION III ADDRESS--(MUST BE COMPLETED) <br /> DBA OR FACILITY NAVE NAMEOFOPERATOR <br /> ADDRE NEAREST CROSS STREET PMCEIA(OPTKINAU <br /> l <br /> CITY NAME STATE ZIP COOE SITE PHONE a WITH AREA CODE <br /> CABOX 7 <br /> TOINa ATE M CORPORATION INDIVIDUAL =PARTNERSHIP 0 DISTRICTS <br /> CAL-AGENCY COUNTY#GENCY (]STATE-AGENCY M FEDERAL#GENCY <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR O RESERVRD ON a OF TANKS AT SITE E.P.A. I.D.a(OP1100AQ <br /> 0 3 FARM Q 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE•WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE IE WITH AREA CODE <br /> tMAILING <br /> PERTY OWNER INFORMATION- MUST BE COMPLETED <br /> CARE OF ADDRESS INFORMATION <br /> RST TADDRESS ✓ box binfio Q INDIVIDUAL O LOCAL-AGENCY STATE AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY#GENCY Q FEDERAL-AGENCY <br /> E STATE ZIP CODE PHONE a WITH AREA CODE <br /> U <br /> III. NK OWNER INFORMATION-(MUST BE COMPLETED <br /> NOF NER CASE OF ADDRESS INFORMATION <br /> MAJLINGhA STREET ESS ✓ CFINDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY (] FEDERALAGENCY <br /> CIN NAME STA ZIP CODEP NE a WITH AREA CODE—"?,Sze—) <br /> �V <br /> ) <br /> IV.BOARD OF EQUALIZATIOPOST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ F4-1-4]-� <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.[D 11.O III. <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 A SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a FACILITY# <br /> n ETTI :0� s <br /> LOCATION CODE -OPTIONAL CENSUS TRACTa -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 /> FORMA-R2 <br /> FORM A(9-90) <br /> \x <br />