Laserfiche WebLink
`Or ! <br /> STATE OF CALIFORNIA ,� <br /> STATE WATER RESOURCES CONTROL BOARD • A`��� i e <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORMA _ 1. <br /> COMPLETE THIS FORM FOR EACH UMrrY,STrE <br /> 77 1 NEW PERMIT 3 RENEWAL PERMIT5 CHANGE OF INFORMATION 7 PEE RMANENTLY LOSED SITE <br /> MARE ONLY <br /> ONE ITEM �� 2 INTERIM PERMR Q A AMENDED PERMR 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION & ADDRESS-IMUS7 BE COMPLETED) <br /> DBA OR 1ACCILITYNAME /� NAME OF OPERATOR <br /> AODR �G/Iv/:�l L'n /�/A'`K \•` I PARCEL#(DPTIONAU <br /> NEAREST CROSS STREET <br /> i ki LM <br /> CI NAME r , / STATE ZAP CODE SITE PHONE!WITH AREA CODE <br /> f <br /> CA <br /> ( TO DIBox C TE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q DISTRICTS <br /> LOCAL-AGENCY <br /> Q COUMYaGENCY Q STATEAGENCV Q FFDERAl+1GEl✓rY <br /> E2 DISTKiBUTOR ✓ IF INDIAN !OF TANKS Al SITE E.P.A L D.!(000INrq <br /> \OF BUSINESS I GAS STATION Q O RESERVATION <br /> G"1 3 FARM ..&'PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> ..EMERGENCY C6NTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> ---' <br /> DAYS: NAME(LAST,FIRSTI PHONE l WITH AREA LODE DAYS: NAME(LAST.FIRST) <br /> 114 r ter L)L I-Oci -�[[ff(o ^3 7 <br /> NIGHTS: NAME(LAST.FIRS PHONE!WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> PHONE! F c <br /> it. PROPERTY OWNER INFORMATION• MUST B OMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> l Sia l ✓ LL `4 rvn NdrY h-- <br /> MAILING R STREET ADDRESS b.0 ww[ Q INDIVIDUAL Q LOCAL-AGENCY Q 5rATE-AGENCY <br /> ( /d L1 -7 S t 5 u ^ IQ CORPOMTION Q PARTNERSHIP Q COUNTY.AGENCY Q FEDEML-AGENCY <br /> - ST ZIP CODE PHONE!WITH AREA CODE <br /> CIN N ME ( <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS `1 Em CmAKL# Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGE1&Y <br /> CITY NAME I STATE I LP CODE PHONE!WITH AREA CODE <br /> IV.BOARD EQUALIZATION UST STORAGE FE CCOUNT NUMBER.Call(916)323-9555 it questions arise. <br /> TY(TK) Q F,4141- U <br /> V. PET LEUM UST FINANCIAL RESP Y- (MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ,J I SELF-INSURED Q 2 GUARANTEE `j 3 INSURANCE Q I$UREIY BOND <br /> ✓ UP Pmdi 66 OTHER <br /> Q 5 LETTER OF CREDIT Q 6 EXEMPTION L <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Lecal notification and billing will be sent to the tank owner unless box or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.EH� II.= 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED B SIGNATUREI APPLICANTS TITLE DATE MONTHIDAYNFAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY$1 JURISDICTION It FACILITY% SfJL V'09 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT r -OPTIONAL I SUPVISOR-DISTRICT CODE -OPTIONAL <br /> d / I 3 j <br /> 1 -4,23 C0 ,j a <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FOROMA 5 <br /> FORMA(591) <br />