Laserfiche WebLink
0 ouu t <br /> pt � <br /> STATE OF CALIFORNIA <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD + <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT L] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS E <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S3 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA RFA ILITYNAME IN MEOFOP ATOR <br /> It <br /> AD ESS' NEARES ROSSST ET PARCEL#(OPTIONAL) <br /> /10 <br /> CI E ATE ZIP DE SITE PHONE#WITN AREAC E <br /> ✓ eox -,—,� <br /> TOIN Box CORPORATION 0 INDIVIDUAL PARTNERSHIP LOCAL I�uvoNTYAGENCV I� STATE AGENCY Q FEDERAL <br /> DISTRICTS <br /> TYPE OF BUSINESS [?--IGAS STATION = 2 DISTRIBUTOR q SERVATTION/ IF INDIAN $OF TANKS AT SITE E.P.A. 1.D.$(optional) <br /> 3 FARM O 4 PROCESSOR O 5 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME LAST,FIRST) ZOq PHONE$WITH AREA CODE DAYS; NAMET,FIST) <br /> I1 t SKS 4 9 <br /> NIGHTS: NA E(LAST,FIRST) PHONE$WITH AREA CODE NIGHTS: NAME T,FIRS <br /> sa•�� ' zo - a iPHONE#WITH AREA <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME T CARE OF ADDRESS INFORMATION <br /> �R' STREET ADDRESS ✓ box biMbaU = INDIVIDUAL El LOCAL AGENCY 0 STATE-AGENCY <br /> D ORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAL AGENCY <br /> CI NAM STAT 21P COD PHONES W11 AC(fD <br /> S <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS• ✓ box bindkab INDIVIDUAL D LOCAL-AGENCY STATEAGENCY <br /> I�CORPORATION PARTNERSHIP O COUNTYAGENCY 7] FEDERAL-AGENCY <br /> CITY NAME' - STATE ZIP CODE PHONE$WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO L4141-F <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boz bindicale I SELF-INSURED =2 GUARANTEE 3 INSURANCE L_j 4 SURETY SONO <br /> 0 5 LETTEROFCREDIT =6 EXEMPTION El IN OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[_—] II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# t <br /> 06,1017 <br /> I_p <br /> LOCATIONCODE -OPTIONAL ICENSUSTRACT$ -OPTIONA( SUPVISOR-DISTRICT CODE -OPTIONAL <br /> L / 000$ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY. <br /> FORM Ane-3n FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> /� FORO0.13AA6 <br />