BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

g R f STATE OF CALIFORNIA P fc oo STATE WATER RESOURCES CONTROL BOARD �� g UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W m� .,.ee�,. COMPLETE THIS FORM FOR EAC CILITYISITE MARK ONLY O T NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 CLOSED SRE ONE ITEM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT O 8 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS 4L , /� NEAREST CROSS STREET PARCEL#(OPIONAL) CITY NAME / /?T^` STATE ZIP CODE SITE PHONE#WITH AREA CODE v Box ✓ CA i3�< W - R - TO INDICATE Q CORPORATION Q INDIVIDUAL = PART ERSHIP LOCAL-AGENCY O COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS 0 1 GAS STATION = 2 DISTRIBUTOR0 ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(oplionaq RESERVATION 3 FARM O 4 PROCESSOR 5 OTHER OR O D TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WtTH AREA COD' II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bindicate INDIVIDUAL O LOCAL AGENCY STATE AGENCY CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box IDWk to Q INDIVIDUAL O LOCAL-AGENCY D STATE-AGENCY (�CORPORATION 0 PARTNERSHIP []COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. TY(TK) HO F414]- V. 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED Y' ✓ box toin&ate 1 SELF-INSURED L:D 2 GUARAMEE Q 6 INSURANCE 4 SURETYBOND 5 LETTER OF CREDIT 0 6 EXEMPTON IS OTHER 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.O II.O III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# [l101017-1 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. C\ FORM A(5-91) FOROMA-5\ I l V �-