Laserfiche WebLink
i <br /> ea an e <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD `S y g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ""� �; <br /> COMPLETE THIS FORM FOR EACH FACILrTY/SITE ��a,•°w,.;. <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SIT <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> lG L(� <br /> ADDRESS NEAREST CROSS STREET PARCEL%(OPTIONAL) <br /> �l� L <br /> CITY AME STATE ZIP CODE SITE PHONE%WITH AREA CODE <br /> NBox <br /> �/ CA <br /> T INDICATE Id•ODRPORATION Q INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 1 GAS STATION 2 DISTRIBUTOR 0 ✓ IF INDIAN %OF TANKS AT SITE E.P.A. I.D.%(optimal) <br /> RESERVATION ..}� T <br /> 0 3 FARM 4 PROCESSOR 5 OTHER OR TRUSTLANDS ` '- Io <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS::NAME(LAST,FIRST) PHONED;WITHAREA� _ <br /> CCODE �, DAYS: NAME(LAST,FIRST) <br /> m <br /> NIGHTS: NAME(LA4T.FIRST) PHONE%WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> wB$ <br /> PHONE A WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION•iMUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> FrJ iG <br /> MAILING OR STREET AD,DR1ESS fi,b.lC/y/ ✓ boa nintlnab � INDIVIDUAL � LOCAL-AGENCY � STATEAGENCY <br /> G'"A wo CORPORATION PARTNERSHIP 0 COUNTYAGENCY Q FEDERAL AGENCY <br /> CITY NAME STATEZIP CODE PHONE%WITH AREA CODE <br /> GA 5F 5th� Se25 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> P ( (G <br /> MAILING OR STREET ADDRESS <br /> �A•� ✓ boa intlkate INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> . D &0�, j RPORATION PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL AGENCY <br /> CITY NAME 8/74T,E� ZIP CODE PHONE%WITH AREA COD <br /> l/Yl W� L f <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4]-4] <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa nlMkau LF-INSURED 0 2 GUARANTEE L-1 3INSURANCE O 4 SURETY BOND <br /> O 5 LETTEROFCREOIT =S EXEMPTION O W OTHER <br /> 771 <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 III. <br /> THIS FORM HAS BEEN COMPLET UNDER PE TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED A SIGNATURE), APPLICANTS TITLE DATE MONTH/DAYIYEAR <br /> -5p <br /> g , <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILTrY# 1 S <br /> m FT-T-1 3l 1S9 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT% -OPTIONAL SUPVISOR-DISTRICT DOME .OPTIONAL <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 /> FORM A(5-91) FORDD33A 5 <br /> SINd <br />