Laserfiche WebLink
S7 AT c C F C AL;FC RNI A �.�`w�N <br /> ATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - EO r.' A 3 -iia <br /> COMPLETE THIS FORM FOR EAC' FACILITY;STE <br /> NARK ONLY NEN PERMIT �_ J RENENAL PERMIT j� 5 CHANGE OF INFCRMATICN r I 7 ?EnMAN L SEJ SITE <br /> C')E ITEM 2 NTE71M PSAMIT _ --'_ s AMENCEO PERMIT ; + ,EMP0AAAY SITE CLOSURE � � D ^ <br /> I. FAC;LITY;SIT= INFORMATION& ADDRESS•(MUST BE COMPLE7 ED) ll <br /> :3A;;A%AC;LITY NAME i NAME OF Cr'ER.iiCR <br /> a'C E53 /� i NEAREST CRC.SS STREET PARCEL I ICPTq U <br /> ^:;y.NA't ((/ STATE ZIP COCE SI c Pr,CNE 8 wITH AREA'CCE <br /> 7l�-N I CA SZo ` 20 - � � , <br /> ✓ KX <br /> 70 NGCATE ,_.CCBECRATTCN Q.myv vAI_ PAAi ;;SWP Q LOCAL AGENCY Q COUNTY-AGENCY IQ STATE•AGENCY Q ;E,'EPAL AGENCY <br /> - -- - J6TRICTS <br /> TYPE JF 3USINESS —� ✓ 'F NCIAN i OF TANKS AT SI TE c.P.A. L 0.s(OO(Imal) <br /> 1 _,AS STATION I �. 2 OlS n:3u'CA <br /> RESERVATION <br /> J FARM r- A PgCC'c3SOR Q 5 OTHER CR TRUSTLANOS <br /> EMERGENCY CONTACT PERSCN (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> LAYS: NAME ALAS T,FIRST) PHONE t'NITH AREA COLE DAYS: NAME( T.FI S. <br /> Ca <br /> vIGHTS: .vAME t T,FIR PHONE•WITH AREA COCE NIGIHTS: NAME ILA-ST," <br /> i—' <br /> -_ ourvc g WITLI.fac4:,=c <br /> II. PRCPGRTY OWNER INFORMATION MUST BE CCNlPLE 1^D) <br /> CARE OF AOCRESS INFORMATION <br /> VA;LiNG OR ST c=T AOC ESS ✓V O nOK'� Q !NONIOUAL r' LOCAL aGE9CY iTATE-AGENCY <br /> I Q COAPCRATICII IQ PAATNERSHP Q COUNTY•AGENCY = %E:E,;AL-AGENCY <br /> CITY N,A,MESTA c ZIP COCE PMCNE i WITH AREA CCCE <br /> S`[ A <br /> Ill. TANK OWNER INFORNIAT ION-LM ST BE COMPLETED) <br /> LAME OF OWNER CARE OF ACORESS INFCRMATICN <br /> uAIL,NG OR STREET RESS ✓ X1 Dv O� L___l INOIVIOUAL Q LCCAL•AGE.NCY Q STATE.AGEXY <br /> Q CCAPCRATICN Q PAATNERSHP Q CcUNrY-UKY Q Fu^ERAL A,;_4CY <br /> C:TY NAME STATE I ZIP CC CE PHCNE m WITH AREA COCE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4_74 -�0 10 10[ = ' <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ o w Q 1 SELF-INSURED Q 2 GUARANTEE Q I INSURANCE SAM am <br /> Il Q S £TTEdCFCRECAT Q 6 SxEVPTTCN Q 99 OTI;ER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the t k owner unless box I or It is checked. <br /> F_ E`­1(CNIE 3OX INCtCATING WHICH ABOVE ACORESS SHOULD 3E USED FOR LEGAL NOTIFICATIONS ANO 84LNG_ LX IL= In. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY CF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND QORRECT <br /> APPL•C.AN T'S.NAME IPRW-.0 d Sr-NATURE) APPLICANT'S TITLE 0IC MCNTWOAYNEAR <br /> --07 6- �2 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY s JURISCICT'CN S FACILITY< <br /> CTl 7 -c-, CCD 1 D <br /> LOCATION CCCE -OPTIONAL (CENSUS TRACT s T NAL I SUPVISOR-OISTRICT COCE -OPTIONAL <br /> THIS FORM M ST BE ACCOMPANIED BY AT LEAST(t)OR!ACRE PERMIT APOLICATION• FORM B,UNLESS THIS IS A CHANGE OF STE INFORMATION ONLY. <br /> =ORM A t5-41) PCAOOSSA-S <br /> 1 i <br />