Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :P - <br /> �/^" COMPLETE THIS FORM FOR,EACH FACILITYISITE <br /> MARK ONLY "� 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O ] PERMANENTLY CLOSED.SITE <br /> ONE ITEM Q 2 INTERIM PERMIT Q 4.. AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR _ <br /> NEAREST CROSS STREET PARCEL (OPTIONAL) <br /> (P A <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA- CA C33 J_ o <br /> ✓ BOX 0 CORPORATION ER'INDINWAL O PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> If owner of UST's a public agency,wmplele the following:name of sgerYsorol 61slon,setlion or office which opmeles the UST <br /> TYPE OF BUSINESS1 GAS STATION O 2 DISTRIBUTOR O ✓IF INDIAN #OFTANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM Q 4 PROCESSOR Q 5 OTHER 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(-AST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE CARE OF ADDRESS INFORMATION <br /> MAILING 69STREET ADDRESS ✓ boxton&ata D INDIVIDUAL I1 LOCAL-AGENCY Q STATE-AGENCY <br /> ED CORPORATION O PARTNERSHIP Q COUNTY-AGENCY Q FEDERALAGENCY <br /> CITY NAME <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER '`� CARE OF ADDRESS INFORMATION <br /> 3�jp_ <br /> MAILING OR STREET ADDRESS M.to ndirate QINDIVIDUAL LOCAL-AGENCY QSTATE-AGENCY <br /> CORPORATION E-1PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> W2 F �1b3 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ F4-[4--]-� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boe to inchoate 0 1 SELF-INSURED 0 2 GUARAMEE =3 INSURANCE =4 SURETY BONO = 5 LETTER OF CREDIT = 6 EXEMPTION =T STATE FUND <br /> O 8 STATE FUND&CHIEF FINANCIAL OFFICER LEITER ED 9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O 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.Q II,O III,a <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&S)IGNATUR TANK OWNERS TITLE DATE MONTH/DAYNEAR <br /> /) <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 /> FORMA(8-95) OWNER MUST FILE THIS FOFOH THE LOCAL AGENCY IMPLEMENTING THE UNDERGR*TORAGE TANK REGULATIONS <br />