Laserfiche WebLink
• <br /> STATE OF CALIFORNIA <br /> o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA tit <br /> COMPLETE THIS FORM FOR EACH FAMLITYISITE <br /> MARK ONLY ❑ 1 NEIN PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ G TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> 013A OR FA TYl61AME NAME OF OPERATOR <br /> II1I'ti'4U1.. �rN-C�_ <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓ CORPORA INOIV'kDUAL PARTNERSHIP LOCAL-AGENCY [] COUNTY-AGENCY' O STATE-AGENCY` [] FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS' <br /> I1 owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS Lj 1 GAS STATION 2 DISTRIBUTOR REV IF SERVATION #OF TANKS AT SITE I E.P.A. I.D.#(optional) <br /> F-1 3 FARM 0 4 PROCESSOR5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonat <br /> DAY AVE(LAST,FIRST) PONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME jLAS ,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME('LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> CARE OF ADDRESS INFORMATION <br /> NAME Z — <br /> c <br /> MAILING OR STREET ADDRESS ✓ box b Indicate 0 INDIVIDUAL D LOCAL-AGENCY 0 5TATE-AGENCY <br /> / <br /> [�]CORPORATION E-1PARTNERSHIP © COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME, STATE ZIP COD PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATVON <br /> MAILING OR STREET ADDRESS ./ bond toindlcats 0 INDIVIDUAL © LOCAL-AGENCY © STATE-AGENCY <br /> 0 CORPORATION ELI PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME 5TATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F474- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> k <br /> box lo Indicate U t SELF-INSURED [] 2 GUARANTEE Q3 NSURANCE 04 SURETY BOND <br /> CI 5 LFTrEROFCREDIT D 6 EXEMPTION, [_j 99 OTHER <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❑ II. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY it JURISDICTION A FACILITY <br /> L S �--- <br /> LOCATION CODE •OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPT70NAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFOINATION ONLY. <br /> OWNER MUST FILE THIS F0 M WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIOW FORDo33Afi <br /> FORM A(393) I+f <br />