Laserfiche WebLink
'ggOUR f9 <br /> STATEOFCAUFORNIA ^` '^a <br /> STATE WATER RESOURCES CONTROL BOARD 3 ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A �;o � we <br /> C�(IiORM,�. <br /> COMPLETE THIS FORM FOR EACH ILITYISITE <br /> MARK ONLY E] 1 NEW PERMIT E:] 3 RENEWAL PERMIT 5K5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT D e TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS , -�-, NEAREST CROSS STR Er PARCEL#(OPTIONAL) <br /> CITY AV STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA - 01 a o <br /> ✓ BOX CONPORATION ] INDIVIDUAL ] PARTNERSHIP LOCAL-AOENCY (]COuNrY-AGENCY ED EMATEAGE7ICY 0 FEDEPAL-AGENCY <br /> TO INDICATE DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR / Q ✓ IF INDIAN #OF TANKS AT SITE E.P.A. L D.s(aPNwwD <br /> —�,'/ RESERVATION <br /> Q 3 FARM Q ,LL <br /> 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY 004T PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> if. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ EW birdm, ] INDIVIDUAL Q LOCAL-AGENCY f] STATE-AGENCY <br /> (]CORPORATION ] PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION- MUST BE COM ETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS Ouxb66(m1M ] INDIVIDUAL D LOCALAGENCY ] STATE-AGENCY <br /> CORPORATION ED PARTNERSHIP ]CWNfY-AGENCY = FEDERAL-AGENCY <br /> PH <br /> CITY NAME STATE ZIP CODE ONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT N MISER-Call(918)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 -� <br /> V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L O 11.[= III.O <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 /> IL� [010 11 <br /> LOCATION COOE -OPTIONAL CENSUSTRACT$ -OPTIONAL SUPVISOR-DISTRICT CODE -OiPTpNAL <br /> Oa a3 , &40 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONNLLY.. <br /> FORM A(9.90) O <br />