Laserfiche WebLink
• `` UR <br /> STATE OF CALIFORNIA hie ro� <br /> STATE WATER RESOURCES CONTROL BOARD Wa <br /> t UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE C��fOM1N <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE _ <br /> ONE REM 2 INTERIM PERMIT 0 C AMENDED PERMIT F-1 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME,-„j : NAME OF OPERATOR <br /> ADD M S NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> FAW°^r^f ! <br /> CITY NAME --��ySTATE ZIP CODE.- SITE PHONE#WITH AREA CODE <br /> I G t C/7�Lr� CA <br /> TOINDCATELam!CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> ��! DISTRICTS' <br /> It 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 [A f GAS STATION Q 2 DISTRIBUTOR = RESER INDIAN 1*OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> Q ATION <br /> 3 FARM Q 4'PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> ERGENCY CONTACT PERSUffrRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE ;DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE N S: NAME( AST,FIRST) PHONE#WITH AREA CODE <br /> I OPEIR � �EA-IFOA'IGIATION- MUST BE COMPLETED Y <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAI R ST REBS ✓ box b indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY QFEDERAL-AGENCY <br /> CITY NAME mak► STATE Z 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 IDindicate Q INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate Q I SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> 5 LETTER OF CREDIT =6 EXEMPTION Q 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: <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 DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLYTb A3 <br /> ° <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPWMAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 31 <br /> 1 <br /> THIS FO UST BE ACCOMPANIED BY AT LEAST(1)0R MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATM <br /> FORMA(3193) FOROtp3AR7 <br /> i <br /> 006 <br />