BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD i<4 �j UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH f CILITWSITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMAN ONE ITEM ❑ 2 INTERIM PERMIT Q A AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR FACILITY NAME - NAMEOFOPERATOR ADDRESS NEAREST CROSS STREET PARCELS(OPTIONX) La e �� CITY NAME STATE ZI CODE SITE PHONE a WITH AREA CODE $ of LriA CA 9S 7�0 - L161a TOIN BOX ED CORPORATION p INDIVIDUAL i�PARTNERSHIP p DISTRICTS TGENCY p COUNrY-AGENCY 0 STATE AGENCY O FFDEPALAGENCY TYPE OF BUSINESS ❑ i GAS STATION ❑ 2 DISTRIBUTOR q SERFINVADIIAON A OF TANKS AT SITE E.P.A I.D.a(apfimaD 0 3 FARM Q 4PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: "ME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHnNF#WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bxbiMeNA p INDIVIDUAL p LOCAL AGENCY p STATE-AOFNCY Q CORPOMTION = PARTNERSHIP p CoUNrY-AGENCY p FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ Dox b.Wtl p INDIVIDUAL p LOCAL-AGENCY p STATE-AGENCY =CORPORATION p PARTNERSHIP p COUNrYAGENCY p FMERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323.9555 if questions arise. TY(TK) HQ 4 4 - O 3 V. PETROLEUM UST FINANCIAL RESPONSIBILITY•)MUSTBECOMPLETED)-IDENTIFY THE METHOD(S) USED J bm bYl9da p I SELF-INSURED p 2 GUARANTEE p 3 INSURANCE p A SURETY BUND p 5 LETTER OF CREDIT p 5 EXEMPTION p 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 IL❑ IN. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED 6 SIGNATURE) APPLICANT'S TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY a JURISDICTION a FACILITY a 3 D 3 8 LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL ;;?3d'O THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATIO ONLY. FORM A(5.91) I FOi0077A-5