Laserfiche WebLink
STATEOFCAUFORMA •a./ <br /> STATE WATER RESOURCES CONTROL BOARD r <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A 5, <br /> COMPLETE THIS FORM FOR EACHCILRY/SITE °�< ,,,�•� <br /> MARK ONLY t NEW PERMIT 0 3 RENEWAL PERMIT ltrs CHANGE OF INFORMATION PERMAN�E}Y CLO D SITE <br /> ONE REM 2 INTERIM PERMIT Q 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE V <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE OMPLETED) <br /> DBA OR FACILITYN - I NAM OF OPERATOR <br /> T )S L <br /> ADDRESSNE RE TCROSS STREET PARCELx(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> I/ BOX <br /> T NDICATE CORPORATION O INDIVIDUAL 0 PARTNERS LOCAL-AGENCY COUNTY-AGENCY* STATE-AGENCYFEDERALAGENCY' <br /> M avner of UST Is a public agency,wrtplele the following:nartw of Supervisor of division,section.DISTRICTS n,or o6iw which operates the UST <br /> TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN x OF TAN!A AT SITE E.P.A. I.D.#(opeortal) <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(L ST,FIRST) PHONE#WITH AREA CODE "NIGH <br /> LAST,FIRST) PHONE x WITH AREA CODE <br /> VXj <br /> NIGHTS: NAME(LAST,FIRST) ONE x WITH AREA CODE (LAST,FIRST) PMNE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADD ✓ box b intlicak <br /> INDIVIDUAL LOCAL INSTATE-AGENCY <br /> =CORPORATION PARTNERSHIP COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE x WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b indicate = INDIVIDUAL LOCAL AGENCY 0 STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP Q COUNTYAGENCY 0 FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE <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 METHOD(S) USED <br /> ✓ boa buds aux 0 t SELF INSURED E-1 2 GUARANTEE 0 3 INSUR O 4 SURETY BOND <br /> D 5 LETTEROFCREDIT [__1 6 EXEMPTION OWMER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the to owner unl s 1 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 KNOWL E,IS TRU CORREC <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY �. <br /> COUN # 1 JURISDICTION# FACILITY# <br /> `� <br /> LOCATION CODE -OPTIONAL CENSUS TRAC TIONAL BUPVLBOR-DIS RICT CODE -OPTIONAL \ (� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMA ONLY. <br /> FORM A(3N3) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />