Laserfiche WebLink
STATE OFCALIFORWA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A W n� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION [—] 7 PERMANENTLY CLOSED SITE <br /> ONE REM NI 2 INTERIM PERMIT 0 4 AMENDED PERMIT [::] a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE I FORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAM NAME OF OPERATOR <br /> A RESS NEA STCROSSST ET PARCEIA(OPTIONAL) <br /> o LoQS C . J,v^ ,� 45 <br /> CITY NA E STATE ZIP CODE TE PHO s WITH A CODE <br /> o� Ca _4-Zv Box <br /> z 9 3 zo I <br /> TO INDICATE O CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY E71 COUNTYAGENCY' O STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> If owner d UST is a public agency,anplete the following:nae of Supervisor of oNkbn,section.W office which operates the UST <br /> TYPE OF BUSINESS 0 t GAS STATION = 2 DISTRIBUTOR ✓ IF INDIAN IN OF TANKS AT SITE E.P.A. I.D.a(oplknag <br /> RESERVATION <br /> 0 3 FARM = 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAV ; NAME(LAST,FIRST) PHO a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> o�sL�9S tic o� 9 �-ZPi <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• UST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 1ef. A. ti <br /> MAILING OR STREET ADDRESS I ✓hox blMkeie Q INDIVIDUAL OLOCAL-AGENCY 0 STATE-AGENCY <br /> 1,9575 ED CORPORATION = PARTNERSHIP COUNrY-AGENCY E:1 FEDERAL-AGENCY <br /> CITY NAMESTATE ZIP CODE HONE WITHA ACODE <br /> �D_ �SZ�z 2�1 � 3- zoI <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME/OF�OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET A,D�DOEn$'S/ ✓ box to WI MA INDIVIDUAL f� LOCAL-AGENCY 0 STATE-AGENCY <br /> l/ / y"P v T�� CORPORATION PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME ST ZIP CODE HONE WITHAREACO E <br /> o /oma 95 Z�6 1 9��-aa,/ <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V, PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓box blMbak 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE O 4 SUR ETY BOND <br /> O 5 LETTEROFCREDIT 0 S EXEMPTION 99 OTHER <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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.D II.[::] III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED a SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION 4 FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS.TRA -OPTIONAL SUPVISOR-DISTRICT CODE -OPlxO <br /> 0 2 3 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESSTHIS IS A CHANGE OF SITE INFORMA ON ONLY. <br /> OWNER MUST RLE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) �CJ <br /> ����, <br />