Laserfiche WebLink
�� ,,,.�.,,. �I.•+�'r►. -`!��"s'lAIS�RK,..�t.,.7fi�',�".0#'�:f:."`ter'a.w�;w'7?�+tci?�rtyt�"kr�"�"mss ..._�';a.-!l: <br /> STATE OFCAUFORMA c <br /> STATE WATER RESOURCES CONTROL HOARD - <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACIL(TY/SITE <br /> •c'co-oRa.. <br /> MARK ONLY t NEW PERMIT Q 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) y <br /> OBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS <br /> 7� NEAREST CROSS STREET AR, (OPTCITY NAME /� c;,67— c6o <br /> STATE ZIP CODE JSPIPI <br /> TE PHONE s WRH qEA CODE <br /> CA:- ':j -1/1") <br /> ✓ Box <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY QCOUNTY-AGENCY. <br /> DISTRICTS' Q STATE-AGENCY- Q FEDERAL-AGENCY' <br /> tl Omer of UST Is a public agency,oonplete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS Q t GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN s OF TANKS AT SITE E.P.A I.D.s(optima!) <br /> Q 3 FARM Q 4 PROCESSOR 5 OTHER 0 RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST) PHONE x WIT AREA 000E DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE NIGHTS:NAME(LAST.FIRST) PHONE s WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME�� <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box tolndrats Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> O CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATEZIP CODE PHONE x WITH AREA CODE <br /> U <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> A ::?-' � <br /> MAILING OR STREET ADDR SS ✓ box nindicau Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION- Q PARTNERSHP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> 14 T e__1 <br /> 105 <br /> IV.BOARD OF EQUALIZATION UST STORAGE-FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - —i- I I T17 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box Io Wokats Q 1 SELF-INSURED Q-2 GUARANTEE 3 INSURANCE <br /> . Q l SURETY BOND <br /> a 5 LETTEROFCREDIT Q 6 EXEMPTION Q 99 OTKR <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: L a I III-a <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 6 SIGNED)-. OWNER'S TITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 1 L�Zgf� <br /> LOCATION CODE -OPTIONAL CEWJP TRACT a -OP77ONAL SUPVISOR-DISTRICT CODE-OP770AW L <br /> oI <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESSTHIS IS A CHANGE OF SITE W-(liRMATION ONLY. <br /> FORM A(393) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULA7X= <br /> � �� <br />