Laserfiche WebLink
<t60VA < <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 05 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM O 2 INTERIM PERMIT ­-1 4 AMENDED PERMIT [:] 6 TEMPORARY SITE CLOSURE Z <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED <br /> D RF CILITYNAM <br /> ADDRS NA OF OPERATOR <br /> .5 nee!2W <br /> / O • NEAREST CROJB STREET PARCEL#(OPTIONAL) <br /> STATTEA ZIP CO J SITE PHONE WITH AREA CODE <br /> G�faY� S <br /> TO.1 BOX <br /> INDICATE CORPORATION E:j INDIVIDUAL = PARTNERSHIP D LOAL-AGENCY 0 COUNTY-AGENCY O STATE-AGENCY FEDERAL-AGENCY <br /> RICTS <br /> TYPE Of BUSINESS 3 GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKy AT SITE I E.P.A. I.D.#(optional) <br /> RESERVATION <br /> O 3 FARM O C PROCESSOR ELI 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE I WITH AREA CODE <br /> NIGHTS:NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) #WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bmbinEical# OINDIVIDUAL LOCAL-AGENCY =1STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP Q COUNrYAGENCY O 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 ADDRESS ✓ h#a It Wkal# = INDIVIDUAL D LOCAL-AGENCY STATE AGENCY <br /> 0 CORPORATION O PARTNERSHIP O COUNTYAGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP ED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bonbiM'saN = I SELF-INSURED = ARANTEE O 3 INSURANCE Q 4 SURETY BDND <br /> l71 5 LETTEROFCREDIT EXEMPTION %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.O 11.0 111, <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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 5�1 rH of 111a / h <br /> LOCATION CODE a,0 T/ONAL CENSUS TRACT -QpTlO L SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM BB,,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0033A5 <br />