BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

i.� STATE OF CALIFORNIA ~ STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE 1tl MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PE AN NTLV�D.SIT ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DIZ FA I NAME_ NAMEOFOPERATOR ADDRESSZv�Sf ✓I l/'//�,�iry �� N=RpSs�BEET PARCaI(OPTIONAL) F—L CITYA"E L/•[YwK• STATE ZIP CODE SITE PHONE M WITH AREA CODE 7tec_k4 1 CA ySZ(33 ✓BOX ED CORPORATKIN In 9DMDUAL O PARTNERSHIP ED LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' D FEDERAL.AGENCY- TOINDICATE DISTRICTS Io of UST'Aa*lic apmcy,maglete the lolmnq:mita d supervborokWiMn,wilon ordBm whO MWN to UST TYPE OF BUSINESS ® 1 GAS STATION ❑ 2 DISTRIBUTOR = VoIF IND RESERVATION aOFTANKSATSITE E.P`A. I.�D.*(apfio>ne0 Q Q 3 FARM ❑ d PROCESSOR ❑ 5 OTHER OR TRUST LANDS IIF L 00/ J!/ -( EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAN: ryAME(LAST,FIRS PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE eYcr gl� 9xz-oHz7 NIGHTS: NAM (LAST,FIRST) PHONE 11 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 8 WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION �( p2�t✓ MAILING OR STREET ADDRESS (y ✓ ba to ndcde INDIVIDUALQ LOCAL-AGENCY O STATE-AGENCY P-0. `' ,0. I a0 �j7j(j 0 OORPORATION PARTNERSHIP ED COUNTY-AGENCY 0 FEDERAL-AGDILY CRY NAME /� STATE ZIP CODE PHONE a WITH AREA CODE tMP ak C Cct+t GADr 5 S Z z, I L2o`r)9gL-�(2 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAM FSlCARE OF ADDRESS INFORMATION I 1 .ke Y MAILI}N��G/OR STREET ADDRESS ✓ bofth*A1e RI INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY T-- 6 . �K J� Q CORPORATION Q PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE 9 WITH AREA CODE FY-ev e_t,, CA X15231 Ooet) qSF z-5((2-'7 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓Oosb WkNO 0 1 SELF-INSURED [59 2 GUARANTEE =3 INSURANCE =A SURETY BOND O 5 LETTEROFCREDIT =&EXEMPTION O T STATE FUND D8STATE FUND&CHIEF FINANCIAL OFFICER LETTER = 9STATE FUND LCERTIFICATE OFDEPOSIT O10LOCAL GOVT.MECHANISM O99OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ IIX III.❑ THIS FORM HAS BEEN COMP UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME(PRINTED& EI TANK OWNER'SriTYEAR 1(cgk4La n � � _ O LOCAL AGENCY USE ON COUNTY I JURISDICTION k FACILITY a ` �ZT 11 25d E � 9J LOOATION CODE-OFRIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM 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' N THE LOCAL AGENCY IMPLEMENTING THE UNDERGROW -1TORAGE TANK REGULATIONS FORM A(8-95)