Laserfiche WebLink
/J � 65pUR �a <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a At <br /> e <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY F__] 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY OSED SITE <br /> ONE ITEM L-1 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ✓ f <br /> DBA OR FACILITY NAME� � � � NAME OF OP�RpTOR �C� <br /> ADDRESS <br /> SSS1 NEAREST C,,11RCEL iI ROSS STREET PA (OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> w'ce-'fkcq CA 95 336 <br /> TONDIIC TE C7 CORPORATION 0 INDIVIDUAL PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR / IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 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) <br /> _ P ONE.:#-WITH ARFA Cmi: _ <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME � /J 1 CARE OF ADDRESS INFORMATION <br /> MAILING ORS R�I EIlTADDRESS ✓ box bIndicate 0 INDIVIDUAL Q LOCAL-AGENCY �STATE-AGENCY <br /> Cr (/� V{ 1( e— []CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> ` It-,ler MCI O' ---S <br /> III, TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW ER CARE OF ADDRESS INFORMAT4ON <br /> q 0J-� <br /> MAILING OR STREET ADDRESS ✓ box ID indicate <br /> ® INDIVIDUAL OLOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY•AGENCY FEDERAL-AGF14CY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> ✓1 r CG ZS f) 'zcrl 59-2- Q <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 -I D 10 dCCS <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY- (MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate F__j 1 SFLF�INSURED C 2 GUARANTEE 3 INSURANCE 4 SURETYBOND <br /> L_J 5 LFTTFR OF CREDIT [_ 6 EXEMPTION 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 /> FECKONIE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= 11.[_7 It. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# �� L(7 <br /> LOCATION CODF -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL ) <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-911 FOR0037A-5 <br />