Laserfiche WebLink
STATE OF CALIFORNIA ` <br /> STATE WATER RESOURCES CONTROL BOARD "" o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE In <br /> MARK ONLY 1 NEW PERMIT lij 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY -� ITE <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE O/ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR CILITY NAME OF OPERATOR <br /> -eleven e 21750 <br /> ADDRE NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> >✓ - `,YDSeml+e, Pbwer5 Ave- <br /> CITY NAME STATE Z CODE SITE PHONE#WITH AREA CODE <br /> an�e�..Go CA e)3-1(42 <br /> 61 BOX 19 CORPORATION E::] INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> Nownerof UST#apublragarq.=plele Nefolbwng:Nee,of supervisor of eNision,s ixx,wake which opmetes the UST <br /> TYPE OF BUSINESS �` 1 GAS STATION 0 2 DISTRIBUTOR 0 ✓IF INDIAN I#OFTANKSATSITr E.P.A. I.D.#(optloi <br /> Q 3 FARM O 4 PROCESSOR Q S OTHER RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> PAYS: NAME(LAST,FIRS PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> t 1'1 f 1T " Z`� 4& i <br /> NIGHTS: AME(LAST,FIRSn PH E#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ba�4h ii 25 Co - 7i <br /> 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> MEiE ADDRESS INFO MATION <br /> land r rafi o+ <br /> MAILING OR STREET ADDRESS ✓ boxlonch.h. <br /> A <br /> INDIVIDUAL 1= LOCAL-AGENCY �STATE-AGENCY <br /> 1 ERCCOORPORATION O PARTNERSHIP Q/CJODUNTTYAGGENCY��I� FEDERAL-AGENCY <br /> 17 NAT•E L S I li ZI�ZL- [(I \ INET 1-1 A—Zr.I DEC. <br /> 1111.. TANK OWNER INFORMATION.(MUST BE COMPLETED) <br /> NAIjAE OF O VIER CARE OF ADDRESS INFOR ION <br /> // i0r�d r OrG}I,01mO <br /> M IVIG OR STREET ADDRES �..�✓,eA,box to ndicee Q INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> ©• bl CORPORATION O PARTNERSHIP{ Q COUNTY-AGENCY O FEDERAL-AGENCY <br /> ITY�ANIA� STATE Z2`,107ii IP CODEPWITH AREA--0DE <br /> 2-Z. <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ 4 4- Q Z S i <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bintlkale 1 SELF-INSURED = 2 GUARANTEE (=1 3 INSURANCE I:)4 SURETYBOND WS LET TER OF CREDIT Q 6 EXEMPTION O 7 STATE FUND <br /> []a STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND B CERTIFICATE OF DEPOSIT CD 16 LOCAL GOVT.MECHANISM 0 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.[::] it.❑ III.ffi <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OFPERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> T K5 ER'$�VE(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAYNEAR <br /> Owner- <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> FTI 10 1 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> Ia' d� 5� <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(6.88) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />