Laserfiche WebLink
STATE OF CALIFORNIA Ae <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE to ' <br /> • C'I IIOP N.r <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA <br /> �OR FACILITY <br /> �NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 16011 4 0 SE,0A I 'IG <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> 044--JTe-Lr4 CA K5_75310 �'o 2,31 - 9.9'ZS— <br /> ✓BOX �°CORPORATION INDIVIDUAL C:1 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' 0 STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 8 owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS �41 GAS STATION 2 DISTRIBUTOR RESEIRVINDIAN 1 <br /> ATION #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 0 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PE�R�S,ON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:,1L1A T.FIRST) <br /> CODE <br /> L1G(JS .0-idPHONE <br /> 91 ;ISWITH <br /> YS� DAYS:�+NAME <br /> Ptei _LAr+-,FIRST) PHONE JCj7#WITH 41�y ffG I/ <br /> NIGHTS: NAME(LAST,FIRST) I PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> AUL t&-vL t e- D lSo i k_ 3- 0-S-Z,17 7 TL i v,.P_Ltcj I- 701 sk.'3-,Z 3? <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> K-71-_ (24 cid =CORPORATION 9 PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER ' CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate <br /> �f n �INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> lco� a-d =CORPORATION (] PARTNERSHIP 0 COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME WSTATE ZIP CODE PHONE# STWIT�H AREE <br /> A CODE�fe <br /> �tC,L,rfJ �a 1�tf 8-7__ 70 7 IPJ <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4-1-10 1016171 <br /> rr_v r <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate I SELF-INSURED Q 2 GUARANTEE O 3 INSURANCE =4 SURETY BOND Q 5 LETTER OF CREDIT 0 6 EXEMPTION STATE FUND <br /> a 8 STATE FUND S CHIEF FINANCIAL OFFICER LETTER O 9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 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.❑ it.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> [TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHiDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <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 /> FORMA(6-95) OWNER MUST FILE THIS FOPW THE LOCAL AGENCY IMPLEMENTING THE UNDERGRJWORAGE TANK REGULATIONS <br /> 1 <br />