Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILMISITE a,I <br /> MARK ONLY I NEW PERMIT RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED,SITE <br /> ONE ITEM 3 INTERIM PERMIT IV AMENDED PERMIT ❑ s TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DOA FACIL TY NAM ` NAME OF 0 RATOR <br /> Y LLL 1( e✓>TC+` 4 Ft V� .]I � <br /> ADDRESS NE.AAFST CROSS qTFtEE7 PARCEL/prnoNALI <br /> Cr r;v <br /> CIN NAME If sTATCEA 0 zIPg5 j 15 C0102 ,G1rrEp,{ 93 AgF-t cO QE <br /> ✓BOX 4 CORPORATION O INDIVIDUAL © PARTNERSHIP ©LOCAL-AOENCY 71 COLPM-AGENCY' ,fSTATEAG\)MV =rEroERA1.4GENCY' <br /> TO INDICATE m7RECTS <br /> 'I ownarol USVs r pii*Agony,cmosti Illi foADwK7 rane d zvVilvhol d alvIslon,ii[lion pf 015CA-kh opaillu Ni U97 <br /> TYPE OF BU51NEUS I GAS STATION 2 DISTRIBUTOR d IF INDIAN If OP TANKS AT SIT; E P.A. 1.D.,r(WIDnary <br /> ^� RESERVATION <br /> Q 3 FARM iJ t PROCESSOR [�S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-opllonal <br /> DAY� {LAST,FIRST) PH NE f WITH AREA ICO E DAYS: E(LA$T,FIRS T}� ` ^P NE f WITH AREA D) <br /> N1.N*�A�M�lE(LAS�RRST) _ _ _PHONE a WITH AREA�DE NI r S: NAME i(LA-/STT FTRS �PH�& wr_l'���� <br /> b Q LJ <br /> II. PROPERTY 0 E INFORMATION-(MUST BE COMPLETED) WT1 L/J <br /> NAME CARE OF ADDRESS INFORMATION <br /> 1rMAILING O STREET ADomess I <br /> h aI -,(Jb_Aioh"f Q 6NDNIDUAL Cj LOCAI,•AGENCY [] STATF•AGENCY <br /> 'v (�J GOR90RATION (7 PARTNERSHIP 0 COUNTY-AGENCY C] FEDERAL-h0`c413Y <br /> C{TY NAME 17 ZIP CODE`( PHONE f WITH AREA CODE <br /> 1 l�1ly <br /> III. TANK OWNER INFORMATION.(MUST BE COMPLETED) <br /> r",- OWNFR CAE DRINFORMATION <br /> 0 <br /> MAI 1 G OADDRESS STA ✓ Go to hoIaFi ©iN 0 LCCAL•AGENCY <br /> �J3 Q 57ATS+AGf?!CY <br /> Q r g( 4�J ;1APORATiON PARTNERSHIP Q COUNTY-ADENCY Q FECEAAL-AdB4CY <br /> G1TY N E SSp,�, Z7(7 1-7PHONEWITH ARTA CO®E <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HO 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)--IDENTIFY THE METHOD(S) USED <br /> O I sumsmo 1=12 GL1ARAwru O i INsuwic5 ©w SURETY BOND ® 5 LETTER OF CREDIT © a EXEMPTION LD 7 STATe/;F��'D����,���� <br /> Q I STATE RIND I CHIEF FINANCIAL OFFUR LETTER Q I STATE FUND&CEATIFICATE OF DEPOSIT 0 ID LOCAL GOVT.'MECHAMSM X 99 OTIIER�� <br /> VI. LEGAL N077FICATION AND BILLING ADDRESS Legal neliGcatlon and billing will be sent t0 the tank owner unless box I Or 11 is checked. <br /> CHECK ONE;BOX INDICA-111`4 WHICH ABOVE ADDRESS SHOULD BE:USED FOR LEGAL NOTIFICATIONS AND SILLINO, I.� II.� III, <br /> THIS FOAM HAS BEEN COMPLETED UNDER PENALTY GF PERJURY,AND TO THE BEST OF MY KNOWLEDGE 1S TRUE AND CORRECT <br /> TANK OWNJEJrS NAME{FRSNJTED d SIGN RE} TANK OWNER'S TITLE GATE MiQNTH10AYlYExR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY r JUF41SDICT10N M FACILITY p ' <br /> 400ATION CODE -OPTIONAL CENSUS TRACT f -OPTIONAL 7 <br /> PV1S0R•DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED 9Y AT LEAST(t)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FCAiM A I8-95) <br />