Laserfiche WebLink
• � � �OVR C <br /> STATE OF CALIFORNIA P z <br /> a <br /> STATE WATER RESOURCES CONTROL BOARD s ` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <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 Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY AME NAME OF OPERATOR <br /> ' NEAREST CROSS STREET ±PAR #IOPTIONAL) <br /> AD RFSSSTATE ZIP DFy HONE#WITH AREA CODE <br /> CI NAME <br /> CA tT` <br /> `/ BOX CORPORATION INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY [� COUNTY-AGENCY D STATE-AGENCY F71FEDERAL-AGENCY <br /> TO INDICATE DISTRICTS ✓ IF INDIAN At OF TA K AT SITE I E.P.A. I.D.#{oplionalJ <br /> TYPE OF BUSINES 1 GAS STATION 2 DISTRIBUTOR 0 RESERVATION <br /> 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) PHONE#WITH AREA CODE DAYS: NAME(LAST,'FIRST) <br /> Yy17T{.AflEAC <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> II. PROPERTY OWNER INFORMATION- UST BE COMPLETED <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING DR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL D LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION [� PARTNERSHIP © COUNTY-AGENCY I� FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION-(MUST BE COM ETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box 0o indicate E7 INDIVIDUAL Q LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION I] PARTNERSHIP 0 COUNTY-AGENCY E_j FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT MBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V, PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP TED)—IDENTIFY THE METHOD(S) USED <br /> �] 1 SELF-INSURED =2 GUARA EE 3 INSURANCE CI 4 SURETY BOND <br /> ✓ box bindica[e <br /> � 5 LETTEROFCREDIT Ej 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 WHIGH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L Q IL D III. <br /> THIS FORM HAS SEEN 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 MONTHlDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> X� F= <br /> LflyBY3 <br /> LOCATION C E .Q ZONAL CENSUS TRACT# - L SUPVISOR-DISTRICT CODE -OPTIONAL. <br /> THIS FORM MOST BE ACCOMPANIED BY AT LEAS(1 OR MORE HERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5.91) G�`. T � —+ f L q� �d <br /> �tti) .t x ,Zs � � <br />