Laserfiche WebLink
eeoua �s <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a = <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A Q � <br /> `a <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> Y' ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDR SS-(MUST BE COMPLETED) <br /> DBA FACIL `SAM t N�_0NAM F�OPTOR � <br /> It :* E <br /> ADDS � NEAFjEf� ��TREE-Y�� PARCEL#(OPTI�AL) <br /> CITY A �n <br /> STATE <br /> ^^ ZI .rff / Si PH/ONE#WITH AREA' L�E <br /> E ✓ <br /> CA <br /> BOX <br /> TO INDICATE �CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR 0 RESERVATION #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> E 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> i <br /> _ n EMERGENCY CONTACT PERSON (PRIMARY) r y` EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> O�t�i o CT T)I VfF� E C R � A P�1 C�1 D.J� E(L�ST .TRS <br /> PHONE#WIIH AREA GO <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE HTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CO <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAMf,0 <br /> f —(}' ,f I'] / C#^E�yOF ADDRESS INF <br /> M ION qv <br /> MAILING//ORSTREET 92°RESS ✓box to indicate INDIVIDUAL I� OCAL-AGENCY STATE-AGENCY <br /> �G+00 l_Umino �` ftiaj\ r� CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITYN E STA, ZIP T� PHONE#WITH AREA DE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM Ft WC CAREfJifDrGl ADDRESS tF�M f ION <br /> `Z.. <br /> MAIL NG'OR STREET ADDRgSS ✓(/bolx to indicate INDIVIDUAL 0 LOCAL-AGENCY = STATE-AGENCY <br /> To.) U.1n� [CORPORATION = PARTNERSHIP =COUNTY-AGENCY = FEDERAL-AGENCY <br />$ <br /> CITYE ST ZIPT�� .? PHONE#WITH A �( <br /> S00 (:tC�� OL V <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ [41_41- l <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 2fll SELF-INSURED 0 2 GUARANTEE3INSURANCE 0 4 SURETY BOND <br /> O 5 LETTER OF CREDIT 0 6 EXEMPTION 99 OTHER <br /> i <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 /> aY CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. IL a III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME ITED&SIGNATUR LAP CANT T TLE t DATE MONTH/DAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m FM <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> k <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(5-91) FOR0033A-5 <br /> fax `y <br />