Laserfiche WebLink
eb°un<ea <br /> STATE OF CALIFORNIA °o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ] PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITYNAME A NAMEOFOPERATOR <br /> r rwK H <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> � r s <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> ✓ BOX <br /> TOINDICATE rJ CORPORATION O INDIVIDUAL O PARTNERSHIP 0 LOCAL AGENCY [-I COUNTY-AGENCY <br /> DISTRICTS STATE-AGENCY 0 FEDERAL AGENCV <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) HONE#WITH AREA CODE DAYS: NAME(LAST,FIRST( <br /> NIGHTS: NAME(LAST,FIRST) PHO E# ITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED( <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING ORSEET AD RE S p ✓ baXbinlicale INDIVIDUAL LLOCALAGENCY E-1STATEAGENCY <br /> 6o K CITY NAME / CORPORATION O PARTNERSHIP 0 COUNTY AGENCY FEDERAL-AGENCY <br /> ST I ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> FNAF NER CARE OF ADDRESS INFORMATION <br /> TREET ADDRESS ✓ box I,Nicale Q INDIVIDUAL O LOCAL-AGENCY STATEAGENCY <br /> _ l=CORPORATION = PARTNERSHIP = COUMKAGENCY 0 FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 14 l4j-bI� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ MY bindcale [1 I SELF INSURED F=I 2 GUARANTEE 3 INSURANCE <br /> = 5 LETTEROFCREDIT0 4 SURETY BOND <br /> 0 6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless b or II is thepk6d. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(Pq <br /> INTED&SIGNATURE) APPLICANTS TITLE DATE MONTHADAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY It JURISDICTION# FACILITY# lq� <br /> 3 <br /> LOCATION CODE -OPTIONAL (CENSUS TRACT#-OPTIONAL ISUPVISOR-DISTRICT CODE -OPIIONAL <br /> f-)VY 3 Ga <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS ACHANGE OF S E INFORMATION ONLY. <br /> FORM A(12-D1) FILETHIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGETANK REGULATIONS <br /> FOR0033A P6 <br />