Laserfiche WebLink
C6�- Cg <br /> r w• � <br /> STATE OF CAUFOR14A <br /> STATE WATER RESOURCES CONTROL BOARD bac <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> , i., <br /> � o <br /> � /1 COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY <br /> 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY C <br /> ONE REM 0 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> ORA OR FACILITY NAME n _f NAME OF OPERATOR L f S I'(r JL <br /> ADDRESS s o 3 ' m ct b ( __ n \ NEAREST CR SS STREE� - PARCEL M(O�PfIOLNALO <br /> CITY NAMEs� <br /> [!%2A <br /> DE dw SITE PHONE#WITH AREA CODE <br /> 1oq-4(a b-J-ll(o . <br /> ✓ BOX LOCAL-AGENCY <br /> TO INDICATE CORPORATION INDIVIDUAL PARTNERSHIP (]COUNTY-AGENCY' STATE-AGENCY' (] FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner of UST Is a public agency,complete the following:name o Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS F%yj 1 GAS STATION = 2 DISTRIBUTOR 0 ✓ IF INDIAN is OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS f� <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 /> S;d1.�,c.t oU,� UCt_LAA L1 -3 a43 <br /> NIGHTS: ME(LAST,FIRS PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> SLdcw. a69-4bb-S-$ <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME G"R 1AL SL _I�L1AU CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS nI/box bindicate 0 INDIVIDUAL = LOCAL-AGENCY )�STATE-AGENCY <br /> �� CORPORATION XPARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> i CITY NAME ��G� STATE ZIP CODE PHONE#WITH AREA CODE <br /> e_ 9�2-oS aoq_4(P(P-S 1(6 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER Gkr ' CARE OF ADDRESS INFORMATION <br /> a S�dlA..., <br /> MAILING OR STREET ADDRESS % LL ,w ✓ box b indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> Ij � kvs'C7 0� Q CORPORATION PARTNERSHIP Q COUNTY-AGENCY (� FEDERAL-AGENCY <br /> CIN NAME STATE ZIP COOE PHONE#WITH AREA- CODE <br /> aJ"��"- '}meq -7 4,^3 xqj <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- -10 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bindicate 1 SELF-INSURED 2 GUARANTEE �] 3 INSURANCE (]4 SURETY BOND <br /> D 5 LETTER OF CREDIT Q 6 EXEMPTION 99 OTHER <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: 1.PK if.[::] 111. <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 RANTED&SIG ^ _[jjNER'S TITLE DATE MONTHIDAYNEAR <br /> S �ILA*\,\4eff I WAMO <br /> LOCAL AGENCY USE ONLY a <br /> COUNTY# JURISDICTION# FACILITY#OK242 7 <br /> Fl—g- 1A l 7 " <br /> LOCATION CO -OPTIONAL CENSUS TRACT# -QRTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL q j <br /> 3 �*� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF Sk IWbRMAfION1 ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(�) 5 FOR0003A-i7 <br /> 40, <br />