Laserfiche WebLink
e'Ou. eq <br /> STATE OF CALIFORNIA P <br /> STATE WATER RESOURCES CONTROL BOARD 3 ., <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A o <br /> COMPLETE THIS FORM FOR EACH F LITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE <br /> a SITE <br /> ONE ITEM Ll 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME � ! � NAIL,OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE / SITE PHONE#WITH AREA CODE <br /> 'd4p_Z:7 CA <br /> ✓ BOX RATION INDIVIDUAL = PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> TO INDICATE D <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR / IF INDIAN #OF TAN AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS' N ME(LAST,FIRST) P E# ITH AREA COD DAYS: NAME(LAST,FIRST) 0�4n- �"-17 -8 <br /> ABEA COD <br /> NIGHTS: NAME(LAST,FIRS11 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AR A CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> liG7_740-r �! <br /> MAILING OR STREET ADDRESS ✓ boxtoind'ate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> • ORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> �� STATE ZIP CODE ONE# ITH AREA CODS <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> r <br /> MAILING OR STREET ADDRESS �r ✓ box toinde INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> RPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY` 1NfE STATE ZIP DE2_3� P ONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION U STORAGE FEE ACCOUNT NUMBER-Call(916)3323-9555 if questions arise. 1 j`xj, <br /> TY(TK) HQ 4 4 - p <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate (] 1 SELF-INSURED 0 2 GUARANTEE [_:] 3 INSURANCE 0 4 SURETY BOND <br /> D 5 LETTER OF CREDIT (]6 EXEMPTION 0 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 c cked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ��q I I I wPai-':rL GID <br /> LOCAIONN CODE -OPTIONAL CENSUS TRACT - PTIONAL SUPVISDISTRICT CODE -OPTIONAL15zlo <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 /> FORM A(5-91) FOR0033A-5 <br />