Laserfiche WebLink
OVp C <br /> STATE OF CALIFORNIA144 <br /> t � t l'tdlt, � A`e^ ��•*• 'a <br /> STATE WATER RESOURCES CONTROL ARD ' 1 "EAL T} ° <br /> UNDERGROUND STORAGE TANK PERMIT A� 0 ICE - <br /> (J T/ <br /> COMPLETE THIS FORM FOR EACH FACILITY)SITE A 1 2 <br /> 8 <br /> MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION 8'PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> r)RA FI FACILITY NP.ME NAME OF OPERATOR <br /> �O S 1(L.IF_t, L crvmLJ-Q-- <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> cc33-IN iEwr \4\crKik Q_� cowoy, � LA-,4 lz_z dq3— :a 0 —» <br /> CITY NAME STATE ZIP CODEITE PH NE#WITH AREA CODE <br /> CA °���-y c3 (21z,°!II <br /> ✓ lX)X Les"<CORPORATION n INDIVIDUAL* PART ERSHIP 0 LOCAL•AGENCV <br /> TO INDICATE p.t i�COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If 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 ® 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FI ST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) HONE#WITH AREA CODE <br /> C o M ORr�.A►J �'�q �'� -��l t"2_ ��t D1 A,4sZ 2!z zo$ - <br /> NIGHTS: NAME(LAS P ONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) HONE#WITH AREA CODE <br /> �� "HONE <br /> - 2t�3 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME � CARE OF ADDRESS INFORMATION <br /> P�TC`fv � C}�(11 ST1 A� J. KNOX <br /> MAILING OR S REET ADDRESS `p ✓box ID indicate 0 INDIVIDUAL O LOCAL-AGENCY (] STATE-AGENCY <br /> kC7� E �`��r v LT�` CORPORATION CKPARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME 1 S ZIP O, <br /> © PHONE# ATH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NSF__W OWNER C�^^� �� CARE O-N KESS-�INjFO MATION � n` <br /> MAI1L+IIN',G`�'O�_R-'SSTT�R-EEE�TTADDRRESS 1 ` �! ✓box ID indicate 'v0 INDIVIDUAL V�`LOOCJAL-AGENCY El STATE-AGENCY <br /> 1( o , `L -`�- M CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME(- STAyTE ZIP CODE <br /> PjQo�WITHnq w —O q 1 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. "1 <br /> TY(TK) HQ --11 4-110131- b z{ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> - 2 GUARANTEE <br /> ✓box b Indicate 1 SELF-INSURED �3 INSURANCE !SURETY 90N0 <br /> D 6 LETTER OF CREDIT =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: I. II. 111.IVI <br /> WN I <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(PRINTED&SIGNED) OWNER'S TITLE J y NDATE MONTWDAY/YEAR 19,9 fd <br /> v � <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# l <br /> � � <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT CODE -OP77ONAL <br /> o /S �6 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF INFORMATION ONLY. <br /> FORMA(3193) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> � • <br /> FOROOD9A4t7 <br />