Laserfiche WebLink
foe <br /> STATE OFCALIFORNIA ° c��^ <br /> STATE WATER RESOURCES CONTROL BOARD +,;,� a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� <br /> f011 H,f <br /> COMPLETE THIS FORM FOR EACH FACILITYlSITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT r__j 4 AMENDED PERMIT E] e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY E NAME OF OPERATOR <br /> ADDRESS y} n Ag N EST ROSS STRE PARCEL t(OPfgNALI <br /> in C/mkb� <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA a <br /> TINDICATE CORPORATION ED INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTYAGENCY (] STATE AGENCY 0 FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 3 GAS STATION Q 2 DISTRIBUTOR 0 / IF INDIAN RESERVATION #OF TAS AT SITE I E.P.A. I.D.#(optional) <br /> O 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUSTLANDS ✓'S <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> PHONE#WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box blrNbals E3 INDIVIDUAL D LOCAL-AGENCY O STATE-AGENCY <br /> D CORPORATION = PARTNERSHIP COUNTYAGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET RESS ✓ box bintlbale = INDIVIDUAL LOCAL-AGENCY l�STATE-AGENCY <br /> # 761O CORPORATION O PARTNERSHIP COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME a... p / 11 A TlIIP G DE PHONE#WITH AREA CODE— <br /> 6 GI <br /> IV.BOARD OFF EQUALIZATI1/O,NSI UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box Io hdmale 1 SELF-INSURED =2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> O 5 LEREROFCREDR 5 EXEMPTION 0 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.O III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&S IGNATURE) APPLICANTS TIRE DATE MONTWDAYNEAfl <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACTa -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT T <br /> A)T LLEASTT((1))OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) Fc PhovA-5 <br />