Laserfiche WebLink
0 <br />N%/9 ri <br />STATE OF CALIFORNIA J �'� <br />STATE WATER RESOURCES CONTROL BOARD s '• <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w � Y: <br />C�11�0I M,� <br />C-� COMPLETE THIS FORM FOR EACH CILITYISITE <br />MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY Ct <br />ONE ITEM O 2 INTERIM PERMIT F1 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE <br />I Fere! ITV/Ia1Tc mmRMATInN R annRE_gS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAM <br />NAME OF OPERATOR <br />ADORE <br />g00 <br />IAT <br />PARCEU (OpNA L) <br />CITU M <br />TSTCRO <br />E <br />ZIP CODE_ <br />SITE PHONE WITH AREA CODE <br />CA <br />I- <br />TOI/ BOX <br />INDICATE O CORPORATION INDIVIDUAL = PARTNERSHIP LOCARL-AG NCY 0 COUNTY -AGENCY 0 STATE -AGENCY (] FEDERAL -AGENCY <br />TYPEOF BUSINESS,g I GAS STATION Q 2 DISTRIBUTOR <br />O ✓ IF INDIAN <br />1# OF TANKS AT SITE <br />E. P. A. 1. D. # (0plkn4l) <br />RESERVATION <br />.� <br />3 FARM 4 PROCESSOR Q 5 OTHER <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />J V :NAME (L ST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) <br />1C3lPHONE I WITH AREA MnP <br />- <br />NIGHTS: NAME (LAST, FIRST) I VFHONE # WITH A CODE NIGHTS: NAME (LAST, FIRST) <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED)_ <br />MAILING 08S`MEIffTADDRF/,SS /^` 4 11I" -� ✓ mlblmlale D INDIVIDUAL LJ LOCAL LJ STATEAGENCY <br />1? <br />.1 9-q I 1/ h /J +/9 _ I Q CORPORATION E:I PARTNERSHIP M CWNrY-AGENCY = FEDERAL -AGENCY <br />III. TANK <br />ueuc nc nwi <br />INFUHMA I IUN-(MUJ 1 bt <br />MAILING OR STREET ADDRESS ✓ ml ID Wwals INDIVIDUAL O LOCAL -AGENCY STATE -AGENCY <br />CORPORATION PARTNERSHIP COUNTY -AGENCY (] FEDERAL AGENCY <br />I CITY NAME I STATE I ZIP CODE PHONE M WITH AREA CODE <br />I <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />TY (TK) HQ 4 4 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ 5ol b5bkaU O I SELF INSURED D 2 GUARANTEE T INSURANCE 0 A SURETY BOND <br />(] 5 LETTER OF CREDIT S EXEMPTION Q 99 OTHER <br />771 <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 />CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. O III. <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANTS NAME (PR INTED A SIGNATU RE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br />LUUAL AUtNGY UbL VNLY <br />COUNTY # <br />L3 71 <br />TWIG LDRM MI ICT RF <br />JURISDICTION # <br />RY AT 1 FAST III OR MORE PERMIT APPLICATION <br />P.M. = �ro <br />I <br />B. UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />FORM A(5-91) , I Q/�,/�/ <br />