Laserfiche WebLink
• Q.''JVRG!'S <br /> STATE OF CALIFORNIA r a `tet <br /> STATE WATER RESOURCES CONTROL BOARD wtl 'a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> r•3; . <br /> • C�11-UMI'' <br /> COMPLETE THIS FORM FOR EAC ACILrTY/SITE <br /> MARK ONLY 17 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM n 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE GJ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) / <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> n :/o & <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 4-/o <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> TOINDIC TE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP LOCAL•AGENCYCOUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> ISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN #OF TANKS AT SITE E.P.A <br /> RESERVATION . I.D.#(optional) <br /> Q 3 FARM Q 4 PROCESSOR Q 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) <br /> Gi/ r1/ eG',/ `' ' —3fv5 <br /> NIGHTS: NAME(LAST,FIRST) I PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> CGf r7 ✓ C7 G vC vl ^)Lf<"t <br /> MAILING OR STREET ADDRESS ✓ box b indicate <br /> Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> e r Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> C� h 9� <br /> PMAILING <br /> OWNER INFORMATION.(MUST BE COMPLETED) <br /> NER CARE OF ADDRESS INFORMATION <br /> –/ <br /> �l in P a 5 � �Gri"/ C ,1_/41–r <br /> STREET ADDRESS / . ll ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> V G' Q CORPORATION Q PARTNERSHIP Q COUNTY•AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> olc rn �so9 0s' �_ <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F41'41- p Id. Ig Is <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate Q 1 SELF-INSURED Q 2 GUARANTEE 3 INSURANCE Q 4 SURETY BOND <br /> Q 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 11 is . <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 CORK <br /> APPLICANTS NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m ETTI <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 0 ; . <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 /> FORMA(5-91) FOR A-5 <br />