Laserfiche WebLink
STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> n� s i <br /> �e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °�tiroRN'' <br /> MARK ONLY F7 t NEW PERMIT 0 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 02 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE � _9) <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMENAME OF OPERATOR <br /> t�GO^ S/�j 7i <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITYNAME STATE CODE SITE PHONE 36TH AREA CL�OD�,/ <br /> j// ✓ �x �RPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' STATE-AGENCY' O= FEDERAL-AGENCY <br /> DISTRICTS'TO INDICATE 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 1 GAS STATION 0 2 DISTRIBUTOR0 R SE F INDIAN #OF AT SITE E.R A. I.D.#(optional) <br /> 0 AI <br /> 3 FARM 0 4 PROCESSOR 0 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) 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 CARE OF ADDRESS INFORMATION <br /> C <br /> MAILIN OR STREET ADDRESS ^ ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 11__I PORATION [] PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY Nfft4t STATE ZIP CODE HONE#WITH AREA CODE <br /> nlj� 3z 37-) <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER / CARE OF ADDRESS INFORMATION <br /> MAI ?— <br /> OR STREET ADDRESS n^ ��✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY 0STATE-AGENCY <br /> �?— 11 �� j 2!./ sT L)'CORPORATION (] PARTNERSHIP 000UNTY-AGENCY FEDERAL-AGENCY <br /> CITY►JA ¢ STATE ZIP CODE PSE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBEERR`1-I,Call(916)322-9669 if questions arise. L <br /> TY(TK) HQ K4]- - 0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box iDindicate, U 1 SELF-INSURED Ejj 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> O 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. it. 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 MONTH/DAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> o z3 .6v o <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 REGULATKM <br /> FORM A(3193) FOR0033A-R7 <br />