Laserfiche WebLink
cove <br /> STATE OF CALIFORNIA c <br /> STATE WATER RESOURCES CONTROL BOARD �� u a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �, � <br /> C�II�GXM/.. <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 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 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> ,A6D <br /> A RFACIL1 OR S YNAME NAME OF OPERATOR <br /> �x <br /> 'x/1 NEAREST CROSSSTRE r / PARCEL#IOPTgNAy <br /> CITY NAME STATE ZI�A D / SI?E?H 9 A�010 <br /> CA JJ �9REACODE <br /> U <br /> ✓ BOX 0 INDIVIDUAL 0 PARTNERSHIP O LOCAL COUNTY AGENCY O STATE-AGENCY O FEDERAL-AGENCY <br /> TOINDICATE DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION 2 DISTRIBUTOR ❑ R*/ 11 INDIANATION #OF TANKS AT SITE E.P.MMI" <br /> nI.D.#(op/t�i/m1ao <br /> 3 FARM 4 PROCESSOR [� 5 OTHER OR TRUST LANDS r l-/ MI"I(�(J 17 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DA �T{LA I T) �� PIN <br /> NE#WITH AREA CODE DAY : ryAME ILA T. IRST) 0/6) <br /> /1/D nQQ, �C/ <br /> NIGHTS: NAM (LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: ME(LAST,F STI (� /a%_ IT / <br /> H AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> N E ,L 46fdd DM7 CARE OF ADDRESS INFORMATION <br /> bC <br /> Ml11L NG OR STREET ADDRESS ✓ boxmindkaW D INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 'ter/ - dEl CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY FEDEML#GENCY <br /> CITU NAME SJ24TE ZIP rPDE PHONE#WITH ARD COOE <br /> � ^� <br /> (;qIII. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> N OF OWNER CARE OF ADDRESS INFORMATION <br /> D D �C <br /> MAILING OR STREET ADDRESS ✓ box 0lwicaW l= INDIVIDUAL CD LOCAL-AGENCY 0 STATE-AGENCY <br /> /) 7AIM LeCORPORATION 0 PARTNERSHIP =COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CtDVALAME STKE ZIP CODE PHON #WITH AREA CODE <br /> �Vp gL J� ags <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 114� 3 C D <br /> 08 3 to <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box mliAkate 1 SELF INSURED 0 2 GUARANTEE 3 INSURANCE 0 4;77BDND <br /> (]5 LETTER OF CREDIT =6 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.[z III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MYr NOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIG RE) APPLICANTST E DATE MONTHIDAV R <br /> S s 3 � <br /> LOCAL AGENCY U E ONLY <br /> COUNTY# JURISDICTION# FACILITY It <br /> m a �3 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 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(5-91) FOR0033A 5 <br />