Laserfiche WebLink
UR <br /> STATE OF CALIFORNIA • ^P <br /> STATE WATER RESOURCES CONTROL BOARD 3 , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A '"� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION D 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESSJ_ NEAREST CROSS STREET PARC L#(OPTIONAL) <br /> 790 17' o s o��1`� v� <br /> CITY NAME STATE ZIP CODE <br /> SITE PHONE WITH AREA CODE <br /> CA 5 33G zoy 8Z3- d 7.6 <br /> ✓ <br /> BOX <br /> TOINDICATE E:7 CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS l GAS STATION E::] 2 DISTRIBUTORQ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS 17, <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> c .S4• e--5- -r t?Z3- 6 76 <br /> NIGHTS: NAME(LAST,FAST) ONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 6 f 0 1 - 3 Y/6 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET APDJIESS 101, f box b indiLfate Q INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> s / m - 0/o ORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NE G STATE_9 ZIP COD ONE#WITH AREA COD7 6 E <br /> 3) <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL <br /> Q LOCAL-AGENCY QSTATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 4 4 - p 10 11 <br /> V. 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: I.D II.0 III.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> Kyl EI:IaL5* <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL ® SUPVISOR DISTRICT CODE -OPTIONAL ��•� �'/\ <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(9-90) FOR0033A-R2 <br />