Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD x�� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY T NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION T PERMANENTLY GED, E <br /> ONE REM Q 2 INTERIM PERMIT O 9 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA O AGILITY NAME NAMEOFOPERA <br /> i Qn <br /> ADDRESS NEAREST CROSS STREET PARC #(OPPONAL) <br /> CITY NAME $TACEA 21P ODE SITE PH NE WITH AREA CODE <br /> S�� 9 <br /> ✓ BOX O CORPORATION Q WDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY Q COUNTY AGENCY' Q STATE-AGENCY' FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> gover of UST le a Wbk ager ,o mRlmo the fWb 4 reined sWerneard EMeic n,sectbn oroHice x ech operates the UST <br /> TYPE OF BUSINESS 0 1 GAS STATION 0 2 DISTRIBUTOR O ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optmep <br /> 3 FARM p PROCESSOR 5 OTHER RESERVATION <br /> O 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) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(UST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> It. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Wemmdrme [:DINDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP O couNrY-AGENCY FEDERAUAGENCY <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 ✓ boxtuvdicaw INDIVIDUAL O LOCALAGENCY O STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP 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)322-9669 if questions arise. <br /> TY(TK) HQ F4-[4--] <br /> - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> V We i,dmw 0 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND 0 5 LETTER OF CREDIT Q 6 EXEMPTION =7 STATE FUND <br /> Q 0 STATE FUND&CHIEF FINANCIAL OFFICER LETTER O 9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 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.O It.0 III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION# FACILITY#31 It I <br /> �•/ � n <br /> LOCATION CODE -OPTIONAL CENSUS TRACT tl -OPTIONAL SUPVISOR DISTRICT CODE OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM R,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(6-95) OWNER MUST FILE THIS FO$' "TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO' 'STORAGE TANK REGULATIONS <br /> �� 1 <br />