Laserfiche WebLink
C'Ou. e, <br /> STATEOFCAUFORNIA M1r t� <br /> STATE WATER RESOURCES CONTROL BOARD W v <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A c 3., , os <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM �F� 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS'(MUST BE COMPLETED) <br /> r)AA OR F ILITY NAME NAME OPERATOR <br /> ,�� �� w GL�1 �li�" Ck1fi� I SeS L1J 'C�/�C� Lel iL147 <br /> ADDRESSNEAREST CROSS STREET PARCEL 0(OPTIONA) <br /> CITY NAME STATE ZIP CODE ` SITE PHONE#WITH AREA CODE <br /> C- CA 0, <br /> ✓ BOX <br /> TO INDICATE O CORPORATION INDIVIDUAL PARTNERSHIP LOCAL•AGENCYDISTRICTS' 000UNTY-AGENCY STATE-AGENCY' FEDERAL-AGENCY' <br /> If 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 1 GAS STATION 2 DISTRIBUTOR a ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM O 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYV/ (gSRST) `� HONE WITH-73 <br /> AREA ODE 5_/NI NAME DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> LLA T IRS l'cJ PHLON #WITH AREA COO/DEE! NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAMECARE OF ADDRESS INFORMATION <br /> . vu� <br /> MAILINGORSTRq ET ADDRESS ,,��'y� /� ✓ box to indicate = INDIVIDUAL = LOCAL-AGENCY Q STATE-AGENCY <br /> ^W(�L) (�4� #�/Ci�� /��L� ( CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME <br /> _71 7&� STATE ZIP CODE �PH9NE�#,WI TH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF 0 NERCARE OF ADDRESS INFORMATION <br /> a 41It e'a Gt�Wt <br /> MAILING OR STREET ADDRESS ✓,/byx to indicate 0 INDIVIDUAL LOCAL-AGENCY (] STATE-AGENCY <br /> 14='5 <br /> 'l.� LSI CORPORATION = PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAX STATE ZIP CODE HONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [41-4-]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box toIndicate 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> (] 5 LETTER 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1. II.❑ II <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 8 SIGNED) OWNER'S TLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILn-Y# <br /> FTI <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 9UPVISOR-DI TRIC E -OPTIONAL <br /> Ce � ° <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 /> OWNER MUST FILE THIS FORM W'TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATM <br /> FORMA(3193) FOR003314{7 <br />