Laserfiche WebLink
STATE OF CAL;FCANA C. <br /> 5*'NATER RESOURCES CONTROL BOARD <br /> / UNDERGROUND STORAGE TANK PERMIT APPLICATION • F•.; A 3a <br /> L/ �r`"lra1�•` <br /> l <br /> COMPLETE THIS FORM FCR EACH f ,L(TY;SRE <br /> [7MCAKRONLY LJ I NEW PERMIT 7 RENEWµ PERMIT 5 CHANGE OF INFCRMATICN ) PE.9MAN i Y <br /> :E ITEM 2 -NTERIM PERMIT a AMENCED PERMIT I e �cuPoRARY SITE CLOSURE <br /> I. FACILITYiSITE INFORMATION 3 ADDRESS•(PAUST BE COMPLETED) <br /> :.dA OR FACILII'NAME .// // !r <br /> llJ/' NAME OF OPER Ton <br /> ACC ESS n0 W, �•(L/C�� �~ /rNEARESTCRCSS STREET I PARCEL,CPTONAU <br /> ISTATE I ZIP CODE SITE PHCNE s WITH AREA COCE <br /> -�, <br /> ✓ cx L I CA <br /> TO INOCATE CCRPCRArc.4 INDIVIDUµ '_PARTNEASWP I LOCAL-AGENCY C—J COUNTY AGENCY C STATE AGENCY I� FEDEAAL AGENCY <br /> OSTRICTS <br /> ttPE CF 3lSINESS IJ I CAS STATION 2 OLSTR;aUTCR J '.F INDIAN I'OF TANKS T SITE E.P.A. L O.+ <br /> RESERVATICN IO�"Iall <br /> j 1 7 ;ARM = A P40CESSCA Cl 5 OTHE.i OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> OAYS: .VAME,LAST.FIRST) PHONE.WITH AREA CODE DAYS: NAME(LAST,FIRST( <br /> ,IGH-S: .NAM <br /> E(LAST,FIRST) PlNONE+WITH AREA CODE NgHT4:NAME(LAST.FIRST) <br /> vur a+Y ARc rine <br /> It. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORIAATICN <br /> NA,U'•G OA STREET ADDRESS ✓ anewcw r'1 INDIVIDUAL LOCAL AGENCY <br /> _: STArE'AGENCY <br /> I�CCRPCAAnCN PMLTNERSHP ` COUNTYAGE.NCY C 7MERA443ENCY <br /> DI Y NAME I STATE ZIP COCE I PHONES AREA CCCE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME CF OWNER GRE OF ACOAESS INFORMATION <br /> MAILING OR STREET ADORE SS J v *. NOMAL LOCAL-ACENCY <br /> U STATE-AGBVCY <br /> IJ CORPORATION p PARTWASMP Q CGUNrY.IGENGY p FIMERALAGENCY <br /> CITY NAME I STATE ILP CODE PHONE+MATH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)3239555 if Gu Stions arise. <br /> TY(TK) HQ 44 7 <br /> IVO �1 46 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY ZE M=(S) USED <br /> I SELF-v6UREO =2 GUARANTEE C 1 NSUAANCE = +SURET/BONG <br /> _ S LETTER OF CREGT 17 6 o(Ew nom Q IN OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and blring will be sent to the tank owner unless box I or 11 is checked. <br /> CHECKONE 3OX INCI AT1NO WHCH ABOVE ADDRESS SHOULD aE USED FOR LEGµNOTIFX:ATIONS AND eM1L2NG, L It= RL I—t <br /> TH2S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS 7AUE AND CORRECT <br /> APPL.CAN TS NAME(PRINTED A S*No TORE) APPLCANT$TITL`e GAIL MCNTWOAYNFAR <br /> LOCAL AGENCY USE ONLY z <br /> Gt! <br /> COUNTY* JURISOICT!ON t Q FACILITY t <br /> LCCATgN <br /> C=4 IONAL (CENSUS TRACT+ .OPTIONAL ISUPVISDR•OISTPICTCODE •CF770Nµ <br /> 2 <br /> THIS FCAM MUST 9E ACCOMPANIED 9Y AT <br /> FORMA(5FC LEAST(i)CR!aOAE PERMR APPLICATION• FORM it,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FCROM3A3 <br />