BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

So � STATE OF CALIFORNIA °" STATE WATER RESOURCES CONTROL BOARD .d� UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A O C'55COMPLETE THIS FORM FOR EACH FACILITY/SITE 1 .,•��ois e /1 MARK ONLY 1 NEW PERMIT E�] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS .~.SITE ONE fTEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 3 bl V DBA OR FACILITY NAMES,, NAME OF OPERATOR ADDRESS NEAREST CROSS STIR ET PARCEL#(OPTIONAL) CITY NAME STATEZIP CODE SITE PHONE 4 WITH AREA CODE S C�0 CA gSLe�S ZcxP3 sy / ✓BOX O CORPORATION -E?�INDMDUAL 0 PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY' O STATE-AGENCY' 0 FEDERAL-AGENCY' TO 9AICATE DISTRICTS 1 uenm d UST 0 B PWz aper/,c npISIB Me IOWWI:nenB d apemisor of dNision,$Kfi n or o6be wb'rA openly the UST TYPE OF BUSINESS 0 T GAS STATION 0 2 DISTRIBUTOR Q ✓IFINDIAN N OF TANKS AT SITE E.P.A. I.D.N(opticnep RESERVATION J 0 0 3 FARM Q d PROCESSOR 5 OTHER OR TRUST LANDS / EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAS RST) PHONE#WITH AREA CODE DAYS: NAME(LAST,RRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAS ,FIRST) PHONE B WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPER OWNER INFORMATION-(MUST BE COMPLFTFO) NAME CARE OF ADDRESS INFORMATION MAIUNG OR STREET ADDRESS ✓ Ixxbr'em'a /r� �ND:vIDUAL O LOCAL-AGENCY C3 STATE ACEr+cv Co e` O CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME ` STTAAj�,(/ ZIP CODE PPHHONEE Jr WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWN [ I / CARE OF ADDRESS INFORMATION MAILING OR STREET ADDfl/ES3r' _/ /f �J n ✓ box la irdFale p.IDNIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY ` ` V 7— G— � JL(�+/i J 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME �� STATE ZIP CODE PHONE#WITH A /fin) j i "777'c 1 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ TRP V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓Eox nindiwb O 1 SELF-INSURED 0 2 GUARANTEE3INSURANCE [:14 SURETY BOND 0 5 LETTER OF CREDIT O 6 EXEMPTION O 7 STATE FUND 0#STATE FUND&CHIEF FINANCIAL OFFICER LETT ER O 9 STATE R)ND 6 CERTIRCATE OF DEPOSIT 010 LOCAL GOVT.MECHANISM O99 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 ANO BILLING: I.a II. III THIS FORM H EN COMPLETED UNDE PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERSN (P TEDB NATU TANK OWNER'S TITLE DATE MONTHrDAYNEAR LOCAL AGENCY USE OW Ur 6- COUNTY N JURISDICTION N FACILITY# m I I I LOCATION CODE -OPTIONAL 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 WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(6-95)