Laserfiche WebLink
STATE OF CALIFORNIA <br /> of <br /> / STATE WATER RESOURCES CONTROL BOARD <br /> \ UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILrTYISITE <br /> MARK ONLY —I 1 NEW PERMIT r0r� 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SR <br /> ONE ITEM ,J 2 INTERIM PERMIT u 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE M/ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAMEOF�Op{.RATOR Cot c C a s�l L ldJ G" „c Crl I c <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> (� t 06 �� <br /> CITYNA E STATE ZIP CODE SITE PHONE 4WITHAREA CO E <br /> ark CA $'536 afJ9 f�Z - ig4 <br /> 11 Box <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O1 GAS STATION Q 2 DISTRIBUTOR Q RESERVATTION IF INDIAN 1#OF TANwK'S AT SITE E.P.A. I.D.#(oplianae <br /> FARM Q 4 PROCESSOR Q 5 OTHER ORTRUSTLANDS V <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODEDAVS: NAME(LAST,FIRST) <br /> PHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> � <br /> C1N/ <br /> MAILING OR STREET AODRE$S ✓boxbiMkNe Q INDIVIDUAL Q tfICAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERALAGENCY <br /> CITY NAME $TATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> S CMC <br /> MAILING OR STREET ADORE ✓ box kI Wk Q INDIVIDUAL Q LOCAL-AGENCY Q STATE- <br /> AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 [4:]-F]_j_Fj F] <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to inftab 0 1 SELF INSURED 1 2 GUARANTEE Q 3 INSURANCE 0 4 SURETYeDNO <br /> 0 5 LETTER OF CREDIT 6 EXEMPTION Q W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I r II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIRCATIONS AND BILLING: I. ILO III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPL ICANTS NAM E(P R IN TED&S IGNATURE) APPLICANTS T ITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# —fAC1ETTY <br /> 3.� T I _, d s <br /> LOCATION CODE -OPTIONAL ICENSUSTRACT4 -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 41 zs- G .3-q3 ry <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(12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIO <br /> n FOROOJJA36 <br />