BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA `L STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE n EMARK 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 2 INTERIM PERMIT ❑ 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ❑ # AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE L FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR F IUTY NAME - r NAME OF OPERATOR ADDRES NEAREST CROSS STRE _ pgRCELa(Op77pNgL) 1Red CITY NAME 1 STATE LP CODE "- CA � � SITE PHONE#WITH AREA CODE ✓Box O CORPORATION INDIVIDUAL O PARTNERSHIP TO INDICATE O LOCAL-AGENCY COUNTY-AGENCY' D STATE-AGENCY- O FEDERAL-AGENCY' ff m o(USTua DISTRICTS pdNr eganry,mmpl#1#me blloweNF rem#awparvisordtlrvisun,secion oroffxe xmrh op,Nles me UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOROTH ❑ ✓IF INDIAN A I.D.I(oplAmap 3 FARM aPROESSOR RESERVATION OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE R WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE It. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME Ssife. CARE OF ADDRESS INFORMATION am..c, cta- MAILING OR STREET ADDRESS ✓ bominJI21# =1 INOMDUAL DLOCAL-AGENCY =1 STATE AGENCY O CORPORATION O PARTNERSHIP D COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME STATE LP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bxf#indimt# 0INDMDUAL LOCAL-AGENCY t] STATE-AGENCY ED CORPORATION = PARTNERSHIP D COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓bmbndwY lM 1 SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE 0 A SURETYBOND 0 5 LETTER OF CREDIT O 6 EXEMPTION (]7 STATE FUND 08 STATE FUND&CHIEF RNANCIALOFRCERLETTER O9STATE FUND&CERTIFICATEOFDEPOSIT = 10 LOCAL GOVT.MECHANISM = fi 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: I.❑ II. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK OWNERS NAME(PRINTED&SIGNATURE) TANKOWNERSnTLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY It JURISDICTION It FACILITY# LOCATION DE -OPTIONAL CENSUS TRACT -OPT70NAL SUPVISOR-DISTRICT COD OPTIONAL THIS ORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(6-95)