Laserfiche WebLink
STATE OF CALIFORNIA �- �`� <br /> STATE WATER RESOURCES CONTROL BOARD ;�� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�� :ea <br /> a �� o <br /> COMPLETE THIS FORM FOR EACH tACILRYISITE <br /> MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F7 2 INTERIM PERMIT O d AMENDED PERMIT = e TEMPORARY SITE CLOSURE S3 <br /> I. FACILITYISITE INFORMATION&ADDRESS• (MUST BE COMPLETED) <br /> DSA OR FACILITY NAME NAME OF OPERAT��O77R <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> qJ'O S. A/r vLt l,✓ Pr <br /> CITY NAME STATE ZIP c6DE SITE PHONE a WITH AREA CODE <br /> �We/-'. CA 9SadY ;2- _ 178.1 - S7ds <br /> TO DBox Q CORPORATION Q IMXV10UAL Q PARTNERSHIPo LOCALAGENCY Q COUNIYAGENCY Q STATE-AGENCY Q FEDERAL.AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Q 1 GAS STATION Q 2 DISTRIBUTOR O RE' IF INDIAN <br /> A OF TANKS AT SITE E.P.A. L D.#(uprioW <br /> Q ON <br /> 3 FARM a 3 PROCESSOR Q S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS:NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> Kovock 'f )o - 5-7d3 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- UST BE COMPLETED <br /> NAME 1 CARE OF ADDRESS INFORMATION <br /> AT"I" .C'O✓T7Ck <br /> MAILING OR STREET ADDRESS lMbin6cN# p INDIVIDUAL Q LOCAL AGENCY Q sTATEAGENCY <br /> qjP-0 7S, A/r y f /LJ p CORPORATION Q PAHTNERSMP Q COUNTYAGENCY Q FEDERAL-AGENCY <br /> CITY NAMES/77G(C STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ EM bYMiMM p INDIVIDUAL Q LOCALAGENCY Q FATE-AGENCY <br /> Q CORPORATION Q PAATNERS14P Q COUNTY-AGENCY Q FEDERAL.AGENcY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HO F4-T-4]- LO-4 L>I.? s I (. <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 11.O M. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(FIR WTED A SIGNATURE) APPLICANTS TIRE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY*3JURISDICTIONp EAI/ RER 0��/5' <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL ISUPVISOR-DISTRICT CODE -OPTIONAL <br /> 0 / 2 3Rt 3? -3 N,0 /o/4 z— <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 /> r <br /> FORM A(9-90) FOR <br />