Laserfiche WebLink
• • eeeo�.:e. <br /> STATE OF CALIFORNIA a `% <br /> STATE WATER RESOURCES CONTROL BOARD <br /> a ra <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� ys <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE trJ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORFACILITY NA NAME OF OPERATOR <br /> - <br /> ADDRESS NEfESTCROS?STREEi PARCEL#JOPTKINAL) <br /> CITY NA E STATE ZIP ITE P NE#WITH AREA CODE <br /> l/�E CA zylp 1�U Zs� 9 20 r <br /> ✓ Box <br /> TO INDICATE CORPORATION I1 INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY (]COUNTKAGENCY E:-] STATE-AGENCY O FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS I GAS STATION 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TANKS AT SITE <br /> RESERVATION <br /> = 3 FARM O 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHO14E#WITHAREACODE DAYS: NAME(LAST,FIRST) <br /> O G cel 99rj�Z�r <br /> NIGHTS: NAME(LAST,FIRS PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COOP <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM _4k1 <br /> / CARE OF ADDRESS INFORMATION <br /> _ fir. E 4J <br /> MAILING OR STREETA DRES ✓ box b Indicate = INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> I�CORPORATION = PARTNERSHIP E:] COUNTY AGENCY FEDERALAGENCY <br /> CITY NAME STAT 21P CODE HONE+�WITH ARE CODE <br /> liD 7 alt 2412 22= Zar <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW R CARE OF ADDRESS INFORMATION <br /> � R <br /> MAILING OR STREETADpii)rSS ✓ box biMicale 7] INDIVIDUAL (] LOCAL-AGENCY L� STATE AGENCY <br /> (x(`)�/('1�(#meq CORPORATION 0 PARTNERSHIP =COUNTY-AGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CO �E ON)g WITH A EA CODE <br /> � 9Zo-6 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ b4xb indicate 0 I SELFINSURED E=l 2 GUARAMEE 3 INSURANCE O 4 SURELY BOND <br /> �J 5 LETTEROFCREDT 0 6 EXEMPTION 99 OTHER <br /> Vl. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIOAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> _-. - ---- <br /> LOCATIONCODE OPTIONA CENSUS TgACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> LCA <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 REGULATIONS <br /> • ��/(/// FOg9033ARfi <br />