Laserfiche WebLink
STATEOFCAUFORMA iA <br /> STATEWATERRESOURCES CONTROL BOARDUNDERGRO ND STORAGE TANK PERMIT APPLICATION-FORMA <br /> COMPLETE THIS FORM FOR EACH FACILI VISITE <br /> SE <br /> ® NEW PERMI <br /> r ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E] T PERMANENTLY CLO <br /> MARK ONLY 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> ONE REM 2 INTERIM.''cRMIT ❑ <br /> I. FACILITYISITE INFORMATION&ADDRESS.(MUST BE COMPLETED)NAME of OPERATOR <br /> DPA OR FACILITY NAM �y1 . /il-/S RE;✓CE �O pppCEL%(OPf10NAy <br /> -,p(PIUt STTac A'Ton1 /�Al�' Vfi/`r NEAREST CROSS STREET O - / <br /> ADDRESSADE <br /> '" II <br /> 200 H. w) E fids. STATE ZIP CODE BITE PHONE%WITH AREA L <br /> CITY NAME _ CA FEDERAL-AGENCY' <br /> 2 0 9 x/633 7 S <br /> 5 <br /> ST9.`2 05 <br /> I/ BOX (]OOpppppTlON ti'I INDIVIDUAL O PARTNERSHIP [] LOCAL-AGENCY 0 COUNTY-AGENCY' CD STATE-AGENCY <br /> DSTRICTS' <br /> TOINDICATE owbg: <br /> UST <br /> ✓ IF INDIAN %OF TANKS AT SITE <br /> •N onner d UST le a public agency,mmplele the toil' name d Supervkor d division,section,or office which operates the <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR ® 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (SECONDARY)-GPllonal <br /> EMERGENCY CONTACT PERSON (PRIMARY) DAYS: NAME(LAST,FIRST) PHONE%WITH AREA CODE <br /> PHO NE%WITH AREA CODE Z 174 <br /> DAYS: NAME(LAST.FIRST) LAW <br /> .`��CIF o,74 ¢So3& 80�o D�?E� <br /> 0 C LV PHONE%WITH AREA CODE <br /> PHONE%WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> NIGHT ' NA�(LAST,FIRST) 1I•IL5 20 1 ^1� <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME <br /> t�CE OTEAQ T ✓ poxbindkaN INDIVIDUAL Q LOCAL-AGENCY Ej STATE-AGENCY <br /> MAILING OR STREET ADOR S n 0 CORPORATION PARTNERSHIP 0 COUITY-AGENCY El FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE%WITH AREA CODE <br /> CITY NAME CTLI 7 S20 7 'I �7d o3 <br /> OCAS% <br /> , OnJ <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> A�/C�/✓� A&77_�er ✓ boxblrAiMAS INDIVIDUAL O LOCAL-AGENCY O STATE AGENCY <br /> MAILING OR STREET ADDRESS <br /> / Q �K 0 CORPORATION CI PARTNERSHIP = TY AGENCY <br /> AREEl FEDERAL-AGENCY <br /> NA9 (,(r . 1pLiOn STATE ZIP CODE O PHONE209 7�8O3P <br /> DE <br /> CITY NAME e/'! 9S2 <br /> STG�A'ron� <br /> IV.BOARD OF EQUALIZAT�ION UST S�TOR�AG�jE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- -151�--'N �� �` F <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE <br /> M RHODES) USED o A suRE Y eoNo <br /> O 2 GUARANTEE �gp OTHER <br /> O 1 SELF-INSURED 6 EXEMPTION <br /> ✓ box biMkaN 0 5 LETTER OF CREAT <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 /> AND <br /> RECT <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE•ph UE MONTWDAYNEAR <br /> OWNER'S TITLE <br /> OWNER'S NAME(PRINTED 6 SIGNED) vV �Z Q <br /> �yuJkE�✓aE Roi—Ei2r <br /> CLOCAL;KYFACIJURISDICTIONSUPVISOR-DISTRICT CODE - NCENSUS TRACT% -OPTIO CY/) <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPUCATION- FORM B,UM.ESSTHIS IS A CHANGE OF SITE INFORMATION ONLY.� <br /> OWNER MUST FILE THIS FORM�THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGUULAA�/TIIONS/ �1� <br /> FORM A("3) 0 /-6i G r ✓(_. I <br />