Laserfiche WebLink
STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARDAb <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA s <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />°•,.°mow,. <br />MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY E <br />ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br />I. FACILITYISITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />/'1� Li 0Lro�'�j %t- Z_r <br />NAME OF OPERATOR <br />v.., 61al-I*-,.- <br />ADDRESS <br />NEAREST CROSS <br />.STREET <br />PARCEL # (OPTIONAL) <br />CITY NAME <br />STATE <br />ZIP CODE <br />ITE PHONE If WITH AREA CODE <br />PHONE # WITH AREA CODE <br />✓ BOX Q CORPORATION 0 INDIVIDUAL = PARTNERSHIP 0 LOCAL -AGENCY COUNTY-AGENCYSTATE-AGENCY' FEDERAL -AGENCY' <br />TO INDICATE 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 GAS STATION 2 DISTRIBUTOR <br />✓ IF INDIAN <br /># OF S AT SITE <br />E. P. A. I. D. # (optional) <br />�1 <br />3 FARM 4 PROCESSOR 5 OTHER <br />RESERVATION <br />TR <br />OR UST LANDS <br />-, <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - ontional <br />DAYS: NAME (LAST, FIRST. PHON€ # WITH AREA CODE <br />'6490 <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAM ` . <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to indicate 0 INDIVIDUAL LOCAL -AGENCY STATE -AGENCY <br />_4CL j — 7_ yt o T4, <br />CORPORATION PARTNERSHIP COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />-7 't <br />PHONE # WITH AREA CODE <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />"4 <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to indicate INDIVIDUAL LOCAL -AGENCY (] STATE -AGENCY <br />_4CL j — 7_ yt o T4, <br />= CORPORATION 0 PARTNERSHIP Q COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NA <br />STATE <br />ZIP CODE 9 ' / <br />PHONE It WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. <br />TY (TK) HQ F4]4]- - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to indicate 1 SELF-INSURED = 2 GUARANTEE = 3 INSURANCE Q 4 SURETY BOND = 5 LETTER OF CREDIT O 6 EXEMPTION = 7 STATE FUND <br />8 STATE FUND & CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND & CERTIFICATE OF DEPOSIT D 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: I. ❑ II. ❑ III. <br />r <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 MONTH>DAYNEAR :1 <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION If FACILITY # A=, 17— <br />LOCATION CODE - 9OPTIONAL CENS S TR�GT # - OPTIONAL SUPVISOR • DISTRICT CODE -OPTIONAL <br />�!i ?!"" &� SL4.-> <br />THIS FORM MUST BE ACCOMPANIED BY ATT (1) OR MORE PERMIT APPLICATION - FORM B, UNLESIS IS A CHANGE OF SITE INFORMATION ONLY. <br />FORMA (6-95) <br />OWNER MUST FILE THIS FORDW THE LOCAL AGENCY IMPLEMENTING THE UNDERGRCVSTORAGE TANK REGULATIONS <br />