Laserfiche WebLink
STATE OFCAUFORMA �I/ ��� ' <br /> STATE WATER RESOURCES CONTROL BOARD :��, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <.,,- <br /> MART(ONLY O 1 NEW PERMIT 51 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED 917E <br /> ONE ITEM 2 INTERIM PERMIT E::] A AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 3 ADDRESS-(MUST BE COMPLETED) <br /> nRA OR FACILITYNIA a( 27U C./ a NAME OF OPERATOR <br /> ADDRESS CC( L L G <br /> 3 CAr O n SS STREE7 PaELI(OPfgfU ooa <br /> CITY NAME ^ (^� <br /> STATE P SITE NE ITH REA CODE <br /> /C 6, 6 <br /> ✓BDX <br /> TO INDICATE p CORPORATION p INDIVIDUAL p PARTNERSHIP p LOCAL-AGENCY p COUNTY AWNCY' p STATE OENCY' p FEOEIAL-AGENCY' <br /> N owner d UST b a public agency,complete the NNI DISTRICTS- <br /> owep:narro al SupervMor of tlNbbn.eeelbn,or oHiw which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION p 2 DISTRIBUTOR r i t�nd p ✓ If INDIAN a OF TA A7 SITE E.P.A. I.D.a(oprbtae <br /> 3 FARM Q. A PROCESSOR �5 OTHER RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,F RST)f YY1V\ PHONFJ ITH AREA CODE D S: NAME(LAST,FIRST) �O PH NE a WITH AREA DE <br /> C UUAA -/I _ 3 <br /> NIGHTS: NAM (LAST, IRST) E a H AREA CODE N S: NAME( T, IRAST) PHONE a WITH AREA CODE <br /> _Ijdfm 6 - 36 (� 333-a <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAM ' I,) S Ce C Ch') CARE OF ADDRESS INFORMATION <br /> MAILNG OR STREET ADORES � ep INDIVIDUAL p lOCA4AGENCV pSTATE-AGENCYI u 1I <br /> S�. p CORPORATION PARTNERSHIP p COUNTYAGENCY p FEDERAL-AGENCY <br /> CITY N E S 0 STATE ZIP CODE PHONE a WITH AREA CODE <br /> S Q <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAMEOFOWNER CAROFA DRESS INFOR ATION <br /> J-'rR P1 Ch m 12L ✓ly" l <br /> AM]LW OR STREE ADDRESS ✓bcabl p INDIVIDUAL p LOCAL-AGENCY p STATE-AGENCY <br /> 6/ <br /> p CORPORATION p PARTNERSHIP p COUNTYAmNCY p FEOEMLAGENCY <br /> CITY E1 TE ZIP C C PHONE a WITH AREA COLE <br /> /b e- -7a 0 i <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions ar' , <br /> TY(TK) HQ [4—F4-]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box b Indicate 1 SELF-INSURED GOARANrEE p 3 INSURANCE Ip A SUR ETYBOND <br /> p 5 fETTEROFCREDR p 6 EXEMPTION p N OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.Q III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO TH/JE SESST tF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> NER'SN�E(PRINTED831GNEQ) _/_ � /n/ " N ia_JLYILs.�T A DATE M WDAWYEA/ <br /> LOCALA ENCCYLLUSSE O�'N1N Y /AIN] (Jl(/� <br /> COUNTY J JURISDICTION R FACILITY i <br /> E] <br /> 1 <br /> LOCATION CODE -OPTIONAL CENSUS TRACTI -OPTIONAL SUPVISOR-DISTRICT CODE -OPTN)A(AL <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(393) F000033AA7 <br />