COMPLIANCE INFO_1997-1998 - Laserfiche WebLink

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Pt"Ou. CS C STATE OF CALIFORNIA AP oA STATE WATER RESOURCES CONTROL BOARD 3 UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY r_-] t NEW PERMIT r7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 0 2 INTERIM PERMIT F� 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE d-�- I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACT TY NAME, � !dT L NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) Gt/ A4Mit .l CITY NAME STATE ZIP CODE PTE PHO E#WITH AREA CODE �ie �Y CA IrCJ�� j 3&g- 07/ TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTOR0 ✓ IF INDIAN #OF TAN AT SITE E.P.A. I.D.#(optional) IF 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONNjTACCT PERSON (SECONDARY)-optional DAYS: NAM STjFIRST) HONfH AREA CODE DAYS: NAVE FIRST). PHONE X AREA CODE NIG TS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE at - 334 7- 424 II. PROPERTY OWNER INFORMATION MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION ,Al/47& 4?1L_ AA v1vw'4 MAILING OR STREET ADDRESS !` ✓ box b indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY Avow Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#V4TH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box b indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY l.(fV�- 54a rA* /p/ =CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY = FEDERAL-AGENCY CI HON NAME STATE ZIP CODE PE#WITH AREA CODE � C700/7 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. TY(TK) HQ F4-F4-]- V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 3 ��AWS/401 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL o.� 00, �� THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(9-90) FOR0033A-R2 �� It) Y