Laserfiche WebLink
OUR < <o <br /> STATE OF CALIFORNIA • <br /> STATE WATER RESOURCES CONTROL BOARD sVi <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FO ° <br /> � •-° Yom.: .o <br /> l <br /> 4non�'n <br /> / COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY i I NEW PERMIT C 3 RENEWAL PERMIT CHANGE OF INFORMATION ANEN Y CL <br /> ONE ITEM 2 INTERIM PERMIT C 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE101 1 <br /> 1. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR�QILI NAM`q �� vO NAME OF OPERATOR <br /> ADDRESS <br /> S _ f� D ^ NEAREST C111 ITREET PMCELO(OPTONAL) <br /> CITY NAME /STATE ZIP CODE YSITE P E x W I H A EA CODE <br /> CA -oil <br /> 11 BOX <br /> TO INDICATE COR7 ED INDIVIDUAL J PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY a FEDERAIAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS =_Z_ 1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN x OF TANKS AT SITE E.P.A. L D.x(optional) <br /> RESERVATION <br /> A <br /> 3 FARM Q 4 PROCESSOR 0 5 OTHER OR RESELANDSND$ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) P ONE x WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> z m 2i6 36 - ot 2 <br /> NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE <br /> x WITH AREA CODF <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 23Dn) <br /> MAILIN STREET ADDRESS ✓ becbirdi I INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> ED CORPORATION [= PARTNERSHIP O OOUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATER ZI�CO 0-DcI WITH AREA CODE / Z <br /> GIJo� lcw/QIP ��JJhh%% 7/Y`n' J\ �J[t.�� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATI <br /> IAIL:74RSTREET ADDRESS ✓ Do>t biM4Ale INDIVIDUAL ED LOCAL-AGENCY Q STATE-AGENCY <br /> D v Z..1�� CORPORATION = PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE I PHONE WITH AREA CODE <br /> GaD� ':4 b <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 � <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ bmoMicm. _ 1 SELF-INSURED 2 GUARANTEE O 3 INSURANCE 4 SURETY BOND <br /> _ 5 LETTER OF CREDIT 6 EXEMPTION O 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.= IL 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&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY 11 1 <br /> COUNTY# JURISDICTION# F CILrTY#3997 rL�Q. <br /> LOCATION CODE -OPTIONAL ICENSUS TRACT -OPTIONAL S PVISOR-DISTRICT CODE -OPTIONAL C-� Z �j q <br /> OL- 3 �Lb _�2 <br /> THIS FORM MUST BE ACCOMPANIED BYAT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(S91) A� FOR0037A-5 <br />