Laserfiche WebLink
• 'Lso�q s c <br /> STATE OFCAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY Q t NEW PERMIT 3 RENEWAL PERMIT D114 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR / F <br /> s� �lfGGe l'b S , I E G C c, <br /> ADCREBS NEAREST CROSS STREET PARCEL I(OFTIONAu <br /> CITY NAME STATE ZIP CODE SITE PHONE s WITH AREA CODE <br /> TO INDICATE Q CORPORATION ©MIDIVIDUAL Q PARTNERSHP Q LOCAL-AGENCY Q COUNTY-AGENCY = STATE-AGENCY [] FEDERAL•AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 OAS STATION 0 2 DISTRIBUTORQ ✓ IF INDIAN s OF TANKS AT SIT£ E.P.A- k.D.s(optocnal) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) /e P ON€s WITH AREA CODE GAYS: NAME(LAST,'r+RST} PHONE s WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRSTJ PHONE s WIT)°hAREA4CODE-_ _.NAME jLAST,FIRST) PHONE s WITH AREA CODE <br /> ll. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME � / CARE OF ADDRESS INFORMATION� CI C c~� �l�L7f <br /> MAILING OR STREET ADDRESS ✓ fiat In indicm <br /> c Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> > <br /> /©/ . L LQ'f S fJ 7z �/ =CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY [] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> d `t's'.mac• �?o� YG 3 U L� C <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING 08 STREET ADDRESS ✓ pox n sdirats <br /> Q INDIVIDUAL IQ LOCM-AGENCY 0 STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP WOE PHONE P WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HO 44 - U 1� [� D <br /> V. 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 A80V£ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.E] it.Q 111.E] <br /> THIS FORM HAS BEEN COMPLETED TINDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,!S TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWOAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION 0 FACILITY a 'j L?P I O <br /> �JL 1 171,2 1 1'( 1 <br /> LOCATION CODE .OP77ONAL CENSUS TRACTS -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> C> r �) 3 s-v 3 O- 3 .rJ `1 ?i <br /> II <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF STrE INFORMATION ONLY. <br /> FORM A(9-90 FOROMIA-R2 <br />