Laserfiche WebLink
�sw r <br /> STATE OFCAUFOfiWA o <br /> STATE WATER RESOURCES CONTROL BOARD W dg' :o <br /> UNDERGROUND STORAGE TANK PERMIT APP TION - FORM A ` . ,' <br /> L/ COMPLETE THIS FORM FOR EACH FA YISITE �""°""�� <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED <br /> ONE REM LD 2 INTERIM PERMIT E:1 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS D ` NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME J STATE ZIP CO2� _,7,6 SITE PHONE 0 WITH AREA CODE <br /> CA <br /> T Nv Box DICATE CORPORATION INDIVIDUAL O PARTNERSHIP LDCAL.AGENCY COUNTYAGENCY' ED STATE-AGENCY' I� FEDEPALAGENCY' <br /> DISTRICTS' <br /> R mmr of UST is e public agency,corrpiete the following:name of Supervior of d"lon,traction.or office which operates the UST <br /> IDIAN <br /> TYPE OF BUSINESS 0 1 GAS STATION Q 2 DISTRIBUTOR gESERV MON #OF TANKS AT SITE E.P.0. I.D.#(gotimal) <br /> 0 3 FARM O 4 PROCESSOR Q 6 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 0 WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME '/'/'/'y�•,�'�`' CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓besbintlic#N Q INDIVIDUAL ED LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER �. / �p CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS �/"�/ !�V ✓ bft bird� = INDIVIDUAL LOCAL-AGENCY ED STATE AGENCY <br /> CORPORATION O PARTNERSHIP 11 COUNTYAGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arlse. <br /> TY(TK) HO 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bm bgtlkaN 1�1 SELF-INSURED D 2 GUARANTEE O 3 INSURANCE D 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 6 EXEMPTION O 69 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 11.0 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED B SIGNED) OWNER'S TITLE DATE MONTjWDAY/YRR) <br /> LOCAL AGENCY USE ONLY <br /> couNTv N uualsDlcrION sWab <br /> FACILITY <br /> \Alv �3� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT -OPTIONAL <br /> THIS FORM MUST BEIACICOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE IWORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(3AFOR�m3A4(341 �0 ///7 <br />