Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
STATE OF CALIFORNIA W °O+� <br /> STATE WATER RESOURCES CONTROL BOARD s d� m <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE ro ° <br /> MARK ONLY I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE <br /> I. FACILITY(SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY N E {( NAME OF OPERATOR <br /> Y flies ¢Cd1 1�f2.- •� &A1 nBC. Y&& <br /> ADDRESS CROSS STREET PARCEL If(OPTIONAL) <br /> EAREST <br /> +Wl a �oo `1`1 <br /> CITY NAME STATE ZIP CODE SITE PHONE N WITH AREA CODE <br /> � �C/R CA X157-\T 12th `131 -2pC;6 <br /> .1 BOX fyl CORPORATION [:1 INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> X owrrer of UST U a pubic agency,complete the following:name of sWervisor of dNision,section or OHro which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR Q ✓IF INDIAN 0 O TAN KS AT SI TE E.P.A. I.D.It(optional) <br /> RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> p�VS: <br /> NAME(LAST,FIRST) PHONEAWITH AREACODE DAYS: NAME(LAST,FIRST) PHONE#WITHAREACODE <br /> to hne �1&�l .� rnL2 �a 9B -2 56 cr 0-31 -7413 L� <br /> NIGHTS: NAME(LAST,FI T) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE R WITH AREA CODE <br /> i -29- (1: �eWdi�7m ZA°1-9�13-35i <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> e IY\t <br /> MAILING OR STREET ADDRESS` 1 Q ✓ boxtondeete INDIVIDUAL ID LOCAL-AGENCY = STATE-AGENCY <br /> Ed GORPORATKIN PARTNERSHIP =COUNWAGENCY = FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHON wWITH AREA CODE <br /> r sa fc I — <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> AME OF OWNER CARE OF ADDRESS INFORMATION <br /> a 1cY1 <br /> MAILING OR STREET ADDRESS ✓ tpslo n0'rale D INDMDUAL E3 LOCAL-AGENCY 0 STATE AGENCY <br /> E—� CORPORATION O PARTNERSHIP O COUNTY-AGENCY I1 FEDERAL-AGENCY <br /> NAME - STATE ZIPCODE PHaONE k WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- -LJ_ L� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box 0lngyate1 SELF-INSURED = 2 GUARANTEE =3 INSURANCE 0 4 SURETY BOND O 5 LETTEROFCREDIT 0 6 EXEMPTION O 7 STATE FUND <br /> (� 81STATE FUND&CHIEF FINANCIAL OFFICER LETTER 09STATE RIND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O99 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: I. it.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TA OW AME(PRINTED&SI ATU E) TANK NER'S TITLE/ DATE NTWD Y/YEAR <br /> resrd ( 2 2 <br /> L AL AGENCY USE ONLY <br /> C�OOUU�NTTYY# JURISDICTION k pp <br /> LOCATION CODE-OPTIONAL CENSU TRACT• •OPTI,O,1�INAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> C/ / G/ <br /> THI FORM MUST BE ACCOMPANIED BY AT' T(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS S A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS I,(:.M�TIf UNDENGARAGTANK EiU IONS <br /> FORMA(6-96) A� T ELOYIMPPM C.ER( <br />