Laserfiche WebLink
�eOV9 f9 <br /> STATE OFCAUFORMA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILrrYISITE <br /> MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE�T <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE (. <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILI NAME /� NAMEOFOPERATOR <br /> i H PARCEL 0(OPfpNAW <br /> AD ESS a NEAREST CROSS STREET <br /> 8 Ss 1 <br /> CITY NAME STATE ZIP DE SITE PHONE#WITH AREA CODE <br /> las J G Ca <br /> T INDICATEO O CORPORATION INDIVIDUAL 0 PARTNERSHIP l� LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY' l�FEDERAL-AGENCY' <br /> DISTRICTS' <br /> •B owner of UST Is a public agency,complete the following:narne of Supervisor of division.section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optlanall <br /> ❑ ❑ 0 RESERVATION <br /> ❑ 3 FARM ❑ d PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> D <br /> AYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAM ;CARE ;ADDRESS INFORMATION�� MAILI GOR REETAD S INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> kN PAflTNFA3HIP 0 COUNfY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAM / IP V / 1 PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) d <br /> NAME OF OWNER I CARE OF ADDRESS INFORMATION <br /> S m 0- " <br /> MAILING OR STREET ADDRESS ✓haw bindicals = INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> (]CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#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 /> ✓ box IoIndkate 0 1 SELF-INSURED Q 2 GUARANTEE O 3 INSURANCE O A SURETY BOND <br /> =5 LETTER OF CREDIT O 6 EXEMPTION O 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.❑ II. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY It JURISDICTION# FA <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OP ZONAL 9UPVISOR-DISTRICT <br /> G) OQ . <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION 0 <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS '• c <br /> FORM A(393) �,_ <br /> C. �� S C1]1 GIS rc V'(Iu,l%e G+ °L�i STrk[ — � ✓ "`�`f �V' _ 8 �1��L <br />