Laserfiche WebLink
'bbOVM (y <br /> STATE OFCAUFORNIA \0 of <br /> STATE WATER RESOURCES CONTROL BOARD s' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A mL <br /> e„ ; <br /> COMPLETE THIS FORM FOR EAC ACILITYBITE �o.oew• <br /> MARK ONLY 0 t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Er7 PERMANENTLY E <br /> ONE ITEM F-12 INTERIM PERMIT Q 4 AMENDED PERMIT Q S TEMPORARY SITE CLOSURE 5 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBAORFACIIJTYN E --{) NAMEOFOPERATOR <br /> ADDRESS �v y/ NEAREST CROSS ST ET PARCELS(OPTIONAQ <br /> L <br /> CITY NAME STATE ZIP D SITE PHONE a WITH AREA CODE <br /> CAI/ BOX <br /> d <br /> TOINDICATE CORPORATION INDNIDUAL O PARTNERSHIP LOCAL-AGENCY 0 CAUMYAGENCY STATE AGENCY FEDERAL-AGENCY <br /> DGTFUCTS <br /> TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTOR R V IF INDIIAN ON A OFT AT SITE E.P.A I.D.a(cptI <br /> O 3 FARM O 4 PROCESSOR 0 5 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,FIRS PHONE 4 WITH AREA CODE <br /> 1:;p gin &-3o5 <br /> NIG TS: NAME( F ST) PHONEa OTH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATIO MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ 5^/bindrtaa ED INDIVIDUAL C= LOCAL-AGENCY Q STATEAGENCY <br /> CORPORATION 0 PARTNERSHIP COUNrYAGENCY FEDERALAGEHCY <br /> CITU NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION- MUST BE OMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS bwbiAEbue I= INDIVIDUAL D LOCAL-AGENCY O STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE AOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 -� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Leg I notification and billing will be sent to the tank owner unless box I or II s checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR L GAL NOTIFICATIONS AND BILLING: I.O II.O III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PH INTED&SIGNATURE) APPLX:AN IS TITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION• FACILITY#311 <br /> ® Ma <br /> LOCATION CODE -OP710AIAL CENSUS TRACTS - 710NAL SUPVISOR-DIST RICT CODE -OPTIONAL I�- ,Y/ pL,� <br /> © I 7 TI <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(9-90) FORN03A R2 n <br /> V` <br />