Laserfiche WebLink
STATEOFCAUFORNA <br /> STATE WATER RESOURCES CONTROL BOARD iy o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILffY/SITE <br /> MARK ONLY ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO <br /> ONE R ❑ 8 TEMPORARY EM r2 INTERIM PERMIT ❑ 4 AMENDED PERMIT �" <br /> SITE CLOSURE <br /> /'j 'c�_ <br /> I. FACILITY/SITE INFORMATION 8,ADDRESS-(MUST BE COMPILE LE <br /> DBA OR FACIL <br /> /y/q/ NAME OFOPERATOR <br /> ADDRESS V 1 <br /> NEAREST CROSS STR ET PARCELII(OPTIONAL) <br /> � f <br /> CITY NAME_ ' <br /> _ STATE i Zip <br /> SITE PHONE 0 WITH AREA CODE <br /> I/ BOX CA n f� <br /> TO INDICATE O CORPORATION INDIVIDUAL Q PARTNERSHIP LOCAL AGENCY COUNTY-AGENCY' ED STATE.AGENCV' <br /> 'N inner a UST Is a public agency,complete the lollmin :name of 5 DISTRICTS' FEDERAL-AGENCY <br /> g upervbor of tlMIsOn.sectbn,or ogice Which operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a(opemal) <br /> 0 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUSTRESERLATION <br /> ANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) ps- <br /> d PHONE WITH AREA CODE_ D WITH AREA CODE <br /> 1 9Y NAME(LAST,F ( PHONE a <br /> NX3yTs: NAME.(LAST,FIRST) PHONE a WITH A EA CODE N GFITS: NAME(LAST,FIRST) <br /> j-, / ) ( , PHONE a WITH AREA CODE <br /> If. PROPERTY 0 R COM <br /> NAME CARE OF ADDRESS INFORMATION <br /> I <br /> MAILING OR STREET ADDRESS ✓boa b IMkate <br /> r = INDIVIDUAL E-2LOCALAGENCY =STATE AGENCY <br /> CITY NAME��D V ✓ CORPORATION 0 PARTNERSHIP 1-1COUNTY AGENCY Q FEDERAL AGENCY <br /> JJ STATE ZIP CODE PHONE a WIT AREA CODE <br /> ao <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR ST REST ADDRESS ✓ box binEbaN <br /> 0 INDIVIDUAL [] LOCAL AGENCV Q STATEAGENCY <br /> CITY NAME CORPORATION l= PARTNERSHIP E-1 COUNTY AGENCY FEDERAL AGENCY <br /> STATE ZIP CODE PNONE A WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO 44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bindbale k'ELFINSURE' 2 GUARANTEE <br /> LETTER OF CREDIT O 6 ENEMPTION <br /> OTHER <br /> 7 INSURANCE O 4 SURE`1' ND <br /> s <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: <br /> I.❑ II. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,ANDTO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED 8 SIGNED) OWNER'S TITLE <br /> DATE MONTWOAY/YEAp <br /> LOCAL AGENCY USE ONLY 3 `95 <br /> �C�OU®NT/Y# JURISDICTION# ��FA�C,IILITTYY�OJ��� /�� 7 I <br /> [LOC:ATION.CO:DME �TpNgI `y-'-a-' -1 <br /> CENSUS TRACT-OPTIONAL BUPVISOR- <br /> DISTRICT CODE -OP77ON6AL <br /> THIS FOR 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(3M3) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 0 <br /> / ' *a7 — 9(o FDROD37AA7 <br />