Laserfiche WebLink
*Al a <br /> STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ASITE <br /> COMPLETE THIS FORM FOR EACH FACILT <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ] PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT D 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION 8 ADDRESS-(MUST BE COMPLETED) <br /> D O FACILITY IN NAM OF/OPERATOR <br /> ADD / E\ <br /> NEA TCROS_ SS�gE./ PARCEL Y(OMONAL) -- <br /> CITY <br /> 4 CO57 1K' <br /> STATE ZIP DEQ �� SITE PHONE A WITH AREA CODE <br /> ✓ Box CA 5� <br /> TO INDICATE O CORPORATION 0 INDIVIDUAL D PARTNERSHIP O LOCAL-AGENCY <br /> DISTRICTS COUNTY-AGENCYQ STATE-AGENCY FEDERAL#GENCY <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.#roplianal/ <br /> O 3 FARM 4 PROCESSOR 0 5 OTHER O RESERVATION <br /> OR TRUST LANDS <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 /> NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bml bindicab INDIVIDUAL OLOCAL-AGENCY STATE-AGENCY <br /> _ Q CORPORATION PARTNERSHIP Q COUMV#GEWY E-1 FEDEML#GENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS- ✓ Wm bil E] INDIVIDUAL 7:1 LOCAL-AGENCY-= STATE-AGENCY <br /> O CORPORATION l= PARTNERSHIP 0 COUNTY#GENCV 0 FEDEML#GENCY <br /> CITY NAME' STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION <br /> NUUST <br /> �STOOR�AGGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ L44]-Lscl�L=I--I✓I`� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPL ED)-IDENTIFY THE METHOD(S) USED <br /> ✓ w miMkate C 1 SELF-INSURED l=2_0i D 3 INSURANCE O 4 SURETY POND <br /> J 5 LETTEROFCREDIT Li EXEMPTION IN 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: <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 A SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/VEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATI E OPTIONAL ICENSUS Af'a3A -DliT L !SUPVISOR DISTRICT CODE -OPTMNAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATIONS- FORM B,UNLESS THIS IS A CHANG F SITE INFORMATION ONLY, <br /> FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGOLATIONS <br /> ` FORM3A R6 <br />