Laserfiche WebLink
STATE OF CALIFORNIA c�; <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH ACILRYISITE <br /> MARK ONLY I NEW PERMIT 0 3 RENEWAL PERMIT r5 CHANGE OF INFORMATION 0 T PERMANENTLY CL <br /> u� <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1- FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORFy,�IUTYNAME ' JAl oaQ� NAMEOF OPERATORZ�� <br /> NESTREET PMCEL#(OP(OPTIONAL) <br /> ADDRESS /G%•VjTrh^a// Y <br /> `� <br /> CITY NAMF_ STATE ZIP CODE JAITEPH�Op #WI AREA CODE <br /> //dr�+iQIII ro CA <br /> TO v BOX <br /> INDICATE O CORPORATION INDIVIDUAL (]PARTNERSHIP [-I LOCAL AGENCY COUNTY-AGENCY O STATE-AGENCY Q FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 T GAS STATION 2 DISTRIBUTOR 0 RESERVATDION IAN #OF TANKS AT SITE I E.P.A. I.D.#(apfknal/ <br /> 0 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIR T) /` /PI{ONE#WITH AREAFOfJE / DAYS: NAME(LAST,FIRST) <br /> PHONE N WITH AREA nonp <br /> NIGHTS: NAME(LAST,FIRST) C 6PHHONE aGWITH HAAREA CODENIGHTS:NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME <br /> �/� CARE OF ADDRESS INFORMATION <br /> O <br /> E / <br /> MAILING OR STREET ADDRESS J� 11W blMkate INDIVIDUAL O LOCAL-AGENCY OSTATE-AGENCY <br /> CORPORATION E-1 PARTNERSHIP L-1 COUMYAGENCY FEDERAL-AGENCY <br /> CITU NAME f �- STATE ZIP CODE PHONE#WITH AREA CODE <br /> SA � <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER ✓T CARE OF ADDRESS INFORMATION <br /> MAILING OR OR STRIC/� ✓ SorblMkale INDIVIDUAL LOCAL-AGENCY [71 STATE AGENCY <br /> n (]CORPORATION 0 PARTNERSHIP �COUNTY-AGENCY FEDERALAGENCY <br /> 1_D.-- ,mac- / G _ o <br /> CITU NAM � STA ZIP CODE � 3 PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4j4_j-LZST_ = <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ Oox ml,bicate l� I SELF-INSURED 2 GUARANTEE EA 3 INSURANCE IE]4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION = W OTHER <br /> 71 <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L 0 II. HE 0 <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&SIGNATURE) APPLICANT'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ? <br /> I,OCATIONCODE OPTIONA! CENSUS TRACFI-OPTIONAL SUP ISOR-DISTRICT CODE -OPTIONAL <br /> THIS FJ M MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY. <br /> �OS!A A;12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> �� FOP11p53AR6 <br />