Laserfiche WebLink
• • sw• e <br /> STATE OF CALIFORNIA r -i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> /1 UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A � y <br /> COMPLETE THIS FORM FOR EA FACILITYISITE <br /> MARK ONLY Q I NEW PERMIT E:] 3 RENEWAL PERMIT Ek 5 CHANGE OF INFORMATION [::] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT [:] 5 TEMPORARY SITE CLOSURE L y <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) J <br /> DBAOFi FAQILITYN E NAME OF OPERATOR <br /> ADORE WL//`mlAl TT) NEAR TCR STREET PARCEL 0(OPTIONAL) <br /> CITY NAM STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> TO INDICATE O CORPORATION INDIVIDUAL Q PARTNERSHIP (] LOCAL-AGENCY O COUNTY-AGENCY O STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR O ES✓ IF IVNDIAN #OF TANK SITE E.P.A. I.D.#(optional) <br /> ATION <br /> Q 3 FARM O 4 PROCESSOR 0 5 ORER <br /> THER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> ABEA CODE <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ b#I binEiob Q INDIVIDUAL 0 LOCAL-AGENCY ED STATE-AGENCY <br /> E:2 CORPORATION Q PARTNERSHIP 11 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box oINkm INDIVIDUAL LOCAL.AGENCY O STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY O 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) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box birdka4 Q I SELF-INSURED Q 2 GUARANTEE O 3 INSURANCE <br /> 5 LETTER OF CREDIT =a EXEMPTIOND 4 SURETY BOND <br /> 99 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.❑ II.❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# vkvi����777 J���))'j�Q"� <br /> — JURISDICTION# FACILITY# <br /> � P100DR 302 0] q <br /> LOCATION CODE -OPTIONAL (CENSUS TRACT# - TIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 23. �b 13Z <br /> THIS FORM MUST BE ACCOMPANIED BY Al LEAST(T)OR MORE PERMIT APPLICATION• FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5.91) <br /> FOR�A-5 <br />