Laserfiche WebLink
STATE OFCAUFORWA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />rj COMPLETE THIS FORM FOR EACH FACILITYISITE <br />�bou� e <br />• e�LironN�M . <br />MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br />ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE 200 <br />1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />CARE OF ADDRESS INFORMATION <br />NAME OF OPERAT R <br />C <br />_ <br />6�f5 <br />MAILING OR STREET ADDRESS <br />✓ box loindicate 0 INDIVIDUAL O LOCAL -AGENCY (] STATE -AGENCY <br />�f / <br />✓ box to Indicate F-1 INDIVIDUAL <br />ADDRESS <br />Z ! r�/�1// �� <br />NEAREST CROSS STREET <br />PARCEL # (OPTIONAL) <br />Z_ a W <br />Gam'—L—f <br />CITY NAM <br />PHONE # WITH AREA CODE <br />5?00Z — 9 <br />STATE <br />ZIP CODE <br />SITE PHQNE # WITH AREA CODE <br />G/O�I1�c7 <br />CAP5, <br />- 17 <br />✓ BOX CORPORATION l� INDIVIDUAL Q PARTNERSHIP <br />TO INDICATE <br />0 LOCAL -AGENCY 0 COUNTY•AGENCY <br />STATE -AGENCY' 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 0 2 DISTRIBUTOR <br />0 <br />OF TANKS AT <br />SITE <br />E. P. A. 1. D. # (optional) <br />3 FARM 4 PROCESSOR 0 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />Is <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />NIGHT: NAS, ,SA�FIRST�� `� /POT <br />9 12I -� CODE NIGHTS: NAME (LAST, FIRST) PHONE #WITH AREA CODE <br />If. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />::;744.r <br />4 ,� ,/� <br />Gam!4 RJ Vt r� �i� - <br />MAILING OR STREET ADDRESS <br />✓ box loindicate 0 INDIVIDUAL O LOCAL -AGENCY (] STATE -AGENCY <br />MAILING 05 STREET ADDRESS <br />✓ box to Indicate F-1 INDIVIDUAL <br />LOCAL -AGENCY (] STATE -AGENCY <br />Z ! r�/�1// �� <br />= CORPORATION 0 PARTNERSHIP <br />COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAM <br />STATjj <br />ZIP CODE <br />�j S� <br />PHONE # WITH AREA CODE <br />5?00Z — 9 <br />atm�o <br />g <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />::;744.r <br />MAILING OR STREET ADDRESS <br />✓ box loindicate 0 INDIVIDUAL O LOCAL -AGENCY (] STATE -AGENCY <br />CORPORATION PARTNERSHIP ED COUNTY•AGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. <br />TY (TK) HQ M44- - 9 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED <br />✓ box to indicate 0 1 SELF-INSURED 0 2 GUARANTEE n31NSURANCE 4 SURETY BOND <br />5 LETTER OF CREDIT = 6 EXEMPTION Q 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. 0 III. 0 <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 MONTWDAY/YEAR <br />LOCAL AGENCY USE ONLY r-Y�-,.._ <br />COUNTY # JURISDICTION # FACILITY # <br />LOCATION CODE -OPTIONAL CENSUS TR CT # • OPTIONAL SUPVISOR -DISTRICT CODE -OPTIONAL �rl <br />X3160ZD <br />TIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR 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 REGULATVA <br />FORM A (3193) 0 <br />FOR0033A-R7 <br />