BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

%.*" IFIED PROGRAM CONSOLIDATED FO PH#: FAC#: UNDERGROUND STORAGE TANKS -FACILITY y 1 I lb3 rA pO 3 l� I % (one page per site) UP TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑3.RENEWAL PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED E (Check me item only) ❑ S.TANK REMOVED I3 I O ❑ 4.AMENDED PERMIT ❑6.TEMPORARY SITE CLOSURE am L FACILITY/SITE INFORMATION 3 1 At-c6 em, , BUSINESS PANE(Smen FACn.1TYNAAff+a BRA-DoiigBmios Ad 31 FACILITY m# PRID# vb� ( sy ung I NEAREST CROSS STREET FACILITY OWNER TYPE wl ❑4.LOCAL AGENCY/DISTRICT' ❑ 1.CORPORATION ❑ 5.COUNTY AGENCY' BUSINESS ❑ I.GAS STATION ❑ 3.FARM ❑ 5.COMMERCLV- ❑2.INDIVIDUAL ❑ 6.STATE AGENCY" TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 [_1 3.PARTNERSHIP E] 402 ].FEDERAL AGENCY" TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'Ifowner of UST is a public agency:name ofsupervisor ofdivisim,section or office which opentes REMAINING ATStrustlands? the UST(This is the contact Person for the tank records.) 404 ❑ Yes ❑No 405 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 40t PHONE 409 MAILING OR STREET ADDRESS 409 CITY 410 STATE 411 ZIP CODE 412 PROPERTY OWNER TYPE ❑ 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANKOWNERNAME 414 PHONE 415 MATING OR STREET ADDRESS 416 CITY 417 STATE 418 ZIP CODE 419 TANK OWNER TYPE ❑ 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT 116.STATE AGENCY 420 ❑3.PARTNERSHIP 115.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER ❑99.OTHER ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Cheek me box to indicate which address should beused for legal notifications and mailing. ❑ 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER - Legal notifications and mailing will be sent to the tank owner attless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Cettificatim,-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(F-mmol ae only) 028 1998 UPGRADE CERTIFICATE NUMBER(Fm mal ua o"y) 429 Is 1998 Compliant? UPCF(1/99 revised)