Laserfiche WebLink
<`f'b OjuM+.B CO <br />STATEOFCALIFORNIA ^P <br />STATE WATER RESOURCES CONTROL BOARD �( 44 °o <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />o <br />• cit Foe N� . <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY ®/1 NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION [:] 7 PERMANENTLY CLOSED SITE <br />ONE ITEM F—] 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />S S <br />NAME OF OPERATOR <br />�/-I�i,D S <br />o <br />M <br />ADDRESS <br />NEAREST CROSS STREET <br />PARCEL # (OPTIONAL) <br />800 \A <br />Awy 99 Few1 <br />13 j P �D e& <br />r_ <br />= COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME1� <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHOE S WI`TH�AREA CODE <br />Lcvdi <br />CA <br />C)7 <br />3�7s� <br />✓ Box <br />TO INDICATE CORPORATION E:1INDIVIDUAL 0 PARTNERSHIP Q LOCAL -AGENCY Q COUNTY -AGENCY STATE -AGENCY FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS j GAS STATION 0 2 DISTRIBUTOR <br />✓ IF INDIAN <br />ISOF TANKS AT SITE <br />E.P.A. I. D. # (optional) <br />0 3 FARM 4 PROCESSOR 0 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />EMERGENCY CONTACT PERSON (SECONDARY) - ootional <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />oAt_ -- 1091 <br />ISL L_ 1 1-� ,ems <br />NIGHTS: NAM (LAST, FIRST) PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />Gidid.1 1 <br />box b Indicate = INDIVIDUAL <br />It. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />, <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREETDRESS <br />ISL L_ 1 1-� ,ems <br />A4u,_tT Foe- <br />C214CORPORATION 0 PARTNERSHIP COUNTY -AGENCY = FEDERAL -AGENCY <br />MAILING OR STREET ADD ESS��✓ <br />box b Indicate = INDIVIDUAL <br />= LOCAL -AGENCY STATE -AGENCY <br />13 j P �D e& <br />&R-6RPORATION = PARTNERSHIP <br />= COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME1� <br />STATE <br />ZIP COP <br />PHONE`# CODE <br />� <br />blg <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETEDI <br />NAME OF OWNER <br />©' Cc 1 , <br />CARE OF ADDRESS INFORMATION <br />sAme <br />MAILING OR STREETDRESS <br />✓ box to indicate INDIVIDUAL (] LOCAL -AGENCY STATE -AGENCY <br />A4u,_tT Foe- <br />C214CORPORATION 0 PARTNERSHIP COUNTY -AGENCY = FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE <br />PHONE # WITH AREA CODE <br />�4JZD <br />—' <br />IV. BOARD CF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 739-2582 if questions arise. - <br />TY (TK) HQ 4 4 -1 1 1 ITU 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. ED 11. [7 III. <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANTS NAME (PRINTE NATUR) <br />APPLICANTS TITLE <br />DATE MONTWDAYNEAR <br />A4u,_tT Foe- <br />LOCAL AGENCY USE O&LY <br />COUN Y # JURISDICTION # FACILITY # <br />:34 = /`7y6 <br />LOCATION CODE - OPTIONAL CENSUS TRACT # -OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL <br />-A-60 3;k© <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 (9-90) <br />FOR0033A-R2 <br />r a <br />