BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

.�. ,.f..�.Ivy.,a-yq•lyy y:.. yTWnhi^ r.�;.. !t STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK?PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH F LTTY/SITE `'��•oa"`'. MARK ONLY NEW PERMIT E:] �3 RENE � ,y PERMIT' ,, [:?'S CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED � 1 ; ^ I ONE REM 2 INTERIM PERMIT D 4 AMENDED PERMIT E�] 6 TEMPORARY SITE CLOSURE GJ I. FACILffY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAO FACNL 7ES _fe.�v.` ♦ _. ay ME OF OPERAT — 1tA i ADDRESS * .v. /RET STREET PARCEL#(OPrIONAL) CITY NAME --`� STATE ZIP CODE SITE PHONE I WITH AREA CODE u CABox �JS" 3i3 5556 zoy _ (,oZ T NdCATE O CORPORATION Q INDIVIDUAL =PARTNERSHIP O LOCAL-AGENCY 0 COUNTYAWNCY' 0 SrATE.AGENCY' �,AGENCY' DISTRICTS' 'N owner d UST IB a Public agency,wrrplde the following:name of Supervisor of 6NBbn,Becton,or office which operates the UST TYPE OF BUSINESS O t GAS STATION 0 2 DISTRIBUTOR I� R SEIF RVATION #OF TANKS AT SITE E.P.A 1.D.i(optimal) F7 3 FARM 4 PROCESSOR [ SrbTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: ME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Nq� '.NAME(UST,FIRS O E PHs WITH A CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE W:rS W. ZO If. PROPERTY OWN R INFORMATION• MUST BE COMPLETED NAMEh. l / CARE OF ADDRESS INFORMATION S JJJY"'I ztV.l.� MAILING OR STREET ADDRESS ✓EM bblbtY INDIVIDUAL 1=1 LOCAL-AGENCY O STATE-AGENCY 34 3 / _ O CORPORATION PARTNERS14P 0 COONFYAGENCY J 'EfWEMWIGENCY CRY NAME 8TATE ZIP CODE PHONE#WITH AREA CODE r S z�3 5555 III. TANK OWNER INFORMATION- MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boB b iMkaM 0 INDIVIDUAL O LOCAL AGENCY 0 STATEAGENCY Q CORPORATIONQ PARTNERSHIP I= COUNTY-AGENCY 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 F4]-47- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓box bNdkala 0 I SELF-INSURED 0 2 GUARANTEE 0 INSURANCE O 4 SURETY BOND ^ 0 5 LETTEROFCREDIT 6 EXEMPTION 0 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.E21", it.O III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAYIYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDK)TION 1t FACILffY 8 7-T7 5 111 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISCR-DISTRICT CODE -OPTIONAL /Z- 3 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATKNR- FORM B,UMMSTHISISA ORANGE OF SIE NWMATAIM GILT. j OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTWG THE 11NDERGROUNCSTORAGE TANK REGULATNNN FORM A(3rB3) _ � FOR009SA70 ) sI