Laserfiche WebLink
'L60UA f. <br /> STATE OF CALIFORNIA `i <br /> n STATE WATER RESOURCES CONTROL BOARD �e <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� �� <br /> � . o <br /> I� COMPLETE THIS FORM FOR EACH ILTTY/SITE <br /> MARK ONLY 1 NEW PERMIT n 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 T PERMANENTLY CLOSED SIE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE D <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAO FACILITV/(AA1�NNAME NAME OFOPER(1OR ��n i <br /> a yL--SAI �tipl'2 SS _I ✓lC �dhvY WIG IL - <br /> ADDRESS �1 1 NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> -S 233 Loo�� I� ,kaj g <br /> CITY NAME` STATE ZIPCODE SITE PHONE#WITH AREA CODE <br /> _ G- c�c �o^ CA �jSLoS <br /> v BOX <br /> TO INDICATE RATION U INDIVIDUAL E::] PARTNERSHIP -1 LOCAL-AGENCY O COUNTY#GENCY 0 STATE-AGENCY [D FEDEPAL#GENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS E:] 1 GAS STATION 2 DISTRIBUTORR V IF INDIAN <br /> DDION #OF TANKS AT SITE E.P.A. I.D.#(optional/ <br /> 12-1 <br /> 3 FARM E__i 4 PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE ' DAYS: NAME(LAST,FIRST) <br /> ` <br /> NIGHTS: NAME(LAST.FIRST) #, PHO��ITy Lq CODF,� NIGHTS: NAME(LAST,FIRST) <br /> /r l / (b HONE 8 WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NAMEC� CAR OF ADDRESS INFORMATION <br /> �oQ uvv C,` rtsS lL z %v\r4 k' a <br /> MAILING OR STREET ADDRESS ` ✓ boxb i = INDIVIDUAL = LOCAL-AGENCY Q STATE-AGENCY <br /> -1 v E2•(ZR-PORATION = PARTNERSHIP =COUNTY#GENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PONE#WITH AREA CODE <br /> row y o5_oy 2 6 � -23'�h� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxbiWkM = INDIVIDUAL O LOCAL-AGENCY (] STATE-AGENCY <br /> CORPORATION = PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> W. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ A� =�� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METH_ (S) USED <br /> ✓ box mintlkate i.._� 1 SELF-INSURED 2 GUARANTEE 3INSURANCE 4 SURETY BONG <br /> El 5 LETTER OF CREDIT _- 6 EXEMPTION F-1 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O 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 MONTHIDAYP/EAR <br /> LOCAL AGENCY USE ONLY <br /> 3 <br /> COUNTYtt JURISDICTION# FACILITY# goA0i -5 <br /> _615 l5 1 <br /> LOCATIONCODE -OPTIONAL (CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS NGE OF SITE INFORMATION ONLY. <br /> PORIA A(1291; FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGrREGULATIONS <br /> ` ` FOi109H� <br /> ars/ <br />