Laserfiche WebLink
• • <br /> Pa'aµ., �O <br /> STATE OF CALIFORNIA :e +�� <br /> STATE WATER RESOURCES CONTROL BOARD <br /> 14 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :�� �a <br /> p Y/ C� <br /> 90 COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> dlr�MARK ONLY i NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE Q� <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ScQ�on5 , 1�. Mi CAA l cc.r �c� <br /> ADDRESS NEAREST CROSS STREET PARCEL IOPTIONAIU <br /> lIK 6 SAniJ ays 9cw l <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> 5 c4 �O✓1 CA <br /> TO INDICATE —1 CORPORATION 0 INDIVIDUAL Q PARTNERSHIP Q LOCAL 0 COUNTY-AGENCY STATE AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR / IF INDIAN RESERVATION #OF TANKS AT SITE E.P.A. 1.D.#(.phonal) <br /> Q 3 FARM O 4 PROCESSOR OTHER OR TRUST LANDS 7 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) ,� PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> r4' <br /> (� 4✓4/ m"A/i —3 S r If <br /> NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE NIGHTS: NAME(LAST,FIRST) #WITH AREA COOP <br /> ll. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME �jt\ CARE OF ADDRESS INFORMATION <br /> (� CA '94Vta a kOO <br /> MAILING OR STREET ADDRESS ✓ boxbiMicate O INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> 1s 2D mz D CORPORATION D PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEP NE#WITH AREA CODE <br /> c <br /> C-!:, -I C4 9 S3 � s 3$- 3�f <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> SCI N1 C <br /> MAILING OR STREET ADDRESS ✓ box bimicate O INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNrY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME 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 4 J4]- <br /> V. <br /> -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box <br /> In Indicate SELF.INSUREO 2 GUARANTEE 3 INSURANCE I�4 SURETY eOND <br /> 5 LETTER OF CREDIT O 5 EXEMPTION 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 ch ked. <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 /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEA <br /> LOCAL AGENCY USE ONLY <br /> COUNTY It JURISDICTION# FACILITY# E5G'4/ ) � <br /> m Lf 6 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> z 3 6 3- - 3 <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(5-91) FOR0033A 5 <br /> • A <br />