Laserfiche WebLink
• PZZOVRCP4 <br /> P CO <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �J <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> NAM FOPERATO <br /> DB F ILITY NA �,L��x i, / ,4 0 <br /> "/7x7G1/�t`I'V57r /l NEA TCROS STREET PMCELN(OPfKINAL) <br /> AD /S ! <br /> ST TE ZIP E SITE PHONEN WITH AREA CODE <br /> CITY <br /> T / BO TE CORPORATION E--] INDIVIDUAL O PARTNERSHIP DOISCALAGENCY COUNTY-AGENCY O STATE-AGENCY l� FEDERAL AGENCY <br /> TYPE OF BUSINESS ❑ I GAS STATION 2 DISTRIBUTOR 0 TRICTS ✓ IF INDIAN NOF TANKS AT SITE E.P.A. I.D.N(optional) <br /> ❑ RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST.FIRST) PHONEN WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME <br /> ✓box 0IndicalN 10 INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> MAILING OR STREET ADDRESS <br /> CORPORATION 0 PARTNERSHIP COUNTY AGENCY FEDERAL-AGENCY <br /> _ STATE ZIP CODE PHONE N WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> __ I/ box WmdI ale Q INDIVIDUAL O LOCAL-AGENCY [�STATE-AGENCY <br /> MAILING OR STREET ADDRESS <br /> 0 CORPORATION O PARTNERSHIP 0 COUNTY-AGENCYD FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE N W ITH AREA CODE <br /> CITY NAME <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 14'4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COM ETED)—IDENTIFY THE METHOD(S) USED <br /> 0 <br /> GUARANTEE I� 3 INSURANCE O 4 SURETY BOND <br /> ✓ box binbicale 1 SELF-INSURED <br /> 0 OTHER <br /> 5 LETTER OF CREDIT 5 E%EMPTION �f BN <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: 1.❑ it.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) <br /> APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY �N <br /> C J <br /> OUNTY 9 VV URISDICTION N FACILITY N <br /> 9 <br /> LOCATION CODE -O AL CENSUSTN -O I AL �� <br /> bl _ _ <br /> - p,V � SUPVISOR-DISTRICT 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 INFORMATION ONLY. <br /> FORM A(12.91) FILE THIS FORM WITH THEL CAL AGENCY IMPLEMENTING THE UNDERGROUND ST GULATIONS FOR0033A <br />