Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> / - COMPLETE THIS FORM FOR�EAC�H EKCILITY/SITE / \ <br /> MARK ONLY ' 1 NEW 'PERMIT (= 1 RENEWAL PERMIT UKI CHANGE OF INFORMATKON A <br /> T PERMANENTLY CLOSED ` <br /> ONE REM = 2 '.NTERIM PERMIT = A AMENDED PERMIT = 6 TEMPORARY SITE CLOSURE - - <br /> I. FACILITY/SITE INFORMATION & ADDRESS-(MUST BE COMPLETED) <br /> 08A OR FACILITY NAME ( NAME OF OPERATOR , / ^ <br /> N a�, V /() <br /> ADDRESS I NEARESTC SSS RE ET PARCEL/(OPTIONW <br /> CIN NAME STATE LP COgGO I SITE PHONE 6WITH AREA CODE <br /> CA v//� <br /> J Box \' <br /> 'OINDICATE '�CORPORAi)ON t` INOMOUAL G PARTNERSHIP iJ LOM-AGENCYCj COUMYMsNOY STATE AGENCY FEOERAL.6GENLY Y <br /> 06TPICTS <br /> vPE OF BUSINESS I GAS STATION h 2 OI$TRtBUTOR i� J 1FINOIAN s OF TANKS ATITE E.P.A. L 0.a;Somiolvl) <br /> J RESERVATION <br /> , 7 ] FARM h. • PROCESSOR L5 OTHER 0 I TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON !SECONDARY)-optional <br /> :AYS: NAME(LAST.FIRST) PHONE.WITH AREA CODE DAYS: NAME;LAST.FIRST) <br /> P <br /> NIGHTS: NAME(LAST.FIRST) PHONE•WITH AREA CODE NIGFITS: NAME(LAST.FIRST) <br /> c.' AREA ire <br /> L PROPERTY OWNER INFORMATION•(MUST BE COMPLETED) <br /> .LAME I CARE OF ADDRESS INFORMATION <br /> NAILNGOR STREET ADDRESS i JxP e+ 6 amu -DCA4aGcNGY � SACAGENCY <br /> CORPORATION PARTNERSaP '^,' COUNTY-AGENCY _ PEDE1LL AGENCY <br /> .1.NAME STATE I LP COOS PHONE.WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) ' <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MNL'.NG OR STREET ADDRESS ! mP vrvc>V ;=IM 40JAL LOCA.AGENCY t✓ STATZ-AGENCY <br /> O CORPORATION '—' PARTNERSHIP a COUNTY4rAPJCY !J %MEPALAGEWY <br /> :TYNAME STATE I ZIP COOS PHONE s WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323.9555 it questions arise. <br /> TY(TK) HQ I 4T4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> J mvreka I SBFINCAMED a 2 gIARANTEE (] 1 NSURANCE 6 SWEfY 9oN0 <br /> n s LETTEROFCREDT =6 EYEWmm Q 96 OTHER <br /> `11. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner Unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH A80VE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND 3IULWG: L= ItI= Itt. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE HEST OF MY KNOWLEOGE.IS TRUE AND CORRECT <br /> APW_�CANTS NAME(PRWTED a SIGNATURE) APPUCANTS TITLE DATE MONTHXOAYNE&A <br /> LOCAL AGENCY USE ONLY p� <br /> COU R �/ �j rJ I I- JURISDICTION• FACILITY s <br /> rLLL__1[[�JJ_J yy�!JJ1l [i <br /> LOCATION CODE -CPTKONAL 'CENSUST •OP NAL SUPVISOR-OLSTR -OPTIONAL <br /> Z SI <br /> 'HIS FORM MUST AE ACCOMPANIED BY AT LEAST(1)OR MORE PERMWWPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FOAM A(S91) I\\ MY Ftl0033" <br />