Laserfiche WebLink
\Y\11\ <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> ~A COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT F_� 3 RENEWAL PERMIT F7 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> N� kCE� �E �C�v� Cd .S �►L�1�AV� /� <br /> ADDRESS � NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME \ ` STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> 1 CA zz4c) b _17z)LI <br /> I/ BOX <br /> TO INDICATE Q CORPORATION [FeINDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> DISTRICTS' <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 �' t GAS STATION Q 2 DISTRIBUTORFOR <br /> ✓ IF INDIAN Is OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER 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) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME ,I ARE OF ADDRESS INFORMATION <br /> MAILING ORREEZADDRESS ✓ box b indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> ��/f w� Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGE Y <br /> CITY NAME n �^ STATE ZIP CODE PXQN #WIT EA CODE <br /> lnYl�nl V' C�VJ <br /> III. TANK OWNER 'INFORMATION'(MUST BE COMPLETED) <br /> NAME OF OWNER ' CARE OF ADDRESS INFORMATION <br /> C� <br /> MAILING OR STREET ADDRESS ✓ box b indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> V, Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE 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 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindicate 0 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> D 5 LETTER OF CREDIT Q 6 EXEMPTION Q 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: I. IL F-1 III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAM RINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> R-r�l.�l�t+ch(I� inu � � �� rte►� ".� <br /> LOCAL AGENCY USE ONLY <br /> C3�# JURISDICTION <br /> # �� � ��I� FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> o'L z 3.4a 3Z0 (_ <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 WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATM <br /> FORM A(W93) FOR0033A-R7 <br />