Laserfiche WebLink
45'e-11 I •1 <br /> I zcTz 0* STATE OFCAUFORWA <br /> STATE WATER RESOURCES CONTROL BOARD 3�, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W R:� 1I <br /> Y/-vnn <br /> COMPLETE THIS FORM FOR EAC CILRY/SITE <br /> MARK ONLY I NEW PERMIT J RENEWAL PERMIT 5 CHANGE OF INFORMATION Fl T PERMANEN SED SITE V I <br /> ONE ITEM = 2 INTERIM PERMIT Q 6 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE / 11 <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL (OWIONAL) <br /> Zg( <br /> Al � <br /> CITY NAME STACAZIP CODE 2� / SITE PHONE s WITH ABOX <br /> REA CgDE�� <br /> TINDICATE Q COFPORAnON Q INDIVIDUAL Q PARTNERSHIP Q LO AflLA AGENCY Q COUNTY AGENCY�j Q STATE AGENCY Q FEDDA <br /> EER"LSAGENCY <br /> DtS <br /> TYPE OF BUSINESS Q I GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN a OF TANKS AT SITE E.P.A. L D.t(Mp U <br /> RESERVATION <br /> Q a FARM Q 6 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAM LAST,FIRST) n PHONE A WITH AR CCE DAYS NAME(LAST,FIRSTI <br /> t. <br /> NIGHTS: NAME ILAST,FIRS Lin PHON YWITH AREA CODE NIGHTSS_WNAMM.E(NnLAS✓T, RST) <br /> -PONR.WITH AREA COD, <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> EMAILING <br /> CARE OF ADDRESS INFORMATION <br /> OR STREET ADDRESS ✓ Eoi uv,EitA4 Q INDMOUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Z QI PARTNERSWPME G 7�h I STA ;P COD �O (' _ PHONE s WITH AREA CODE_ <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER ^^ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS �- - -- ✓ EOA nupicAM Q INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY <br /> QI CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL AGENCY <br /> CITY NAME STATE I ZIP CODE PHONE s WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST <br /> STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 �L LCL L L2LZLL� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ , nneicau Q 1 SELF-INSURED Q 2 GUARANTEE Q ] INSURANCE Q A SURETY BOND <br /> Q 5 IETTEROFCREOIT Q 6 EXEMPRON Q 99 OTHER <br /> Vi. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless bo I or 11 is OAk <br /> CHECK ONE BOX INDICATWG WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLWG: L❑ II. III. <br /> ZE <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AkiCaRRE& <br /> APPLICANTS NAME(PRINTED 6 SIGNATURE) APPLICANTS TITLE DATE MONTWDAV/Y EAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a / J JS 2� JURISDICTION x FACILITY x <br /> STTm2H <br /> LOCATION CO TIONAL iCENSUS TRAOPT, <br /> CNA <br /> L SUPVISOR DISTRICT CODE -OPTIONAL <br /> O <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF Sall INFORMATION ONLY. <br /> FORM A(5-91) POR , <br />