BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD o UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ° COMPLETE THIS FORM FOR EACH FACILRYISITE MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ # AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PMCEL#(OPTgNAU ZOoIOg Sir CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE 4 N Ca 11W BOX TOINDICATE O CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY 0 FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR '/ IF INDIAN #OF TANT SITE E.P.A. I.D.%(optim#IJ RESERVATION L3 FARM # PROCESSOR = 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS' NAME LAST, P ONE#WITH AREA ODE DAYS: NAME(LAST,FIRST) FIRS l✓C� 5 ) - 3 NIGHTS: NAME(LAST,HHS 1) PHONE%WITH AREA CODE NIGHTS: NAME(LAST,FIRST) Il. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NA CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bm bintlkaN 0 INDIVIDUAL LOCAL-AGENCY I]STATE-AGENCY ZOp to w =CORPORATION = PARTNERSHIP Q COUNTY-AGENCY O FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE%WITH AREA CODE uG i -9' Z III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADO KESS ✓ boM bintlkate INDIVIDUAL (] LOCAL-AGENCY D STATE-AGENCY UG �({J( I�CORPORATION PARTNERSHIP = COUNTY-AGENCY 0 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) HQ F4—[4-1- V. 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ bDM blWke O I SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE D A SURETY SONO D S LETTEROFCREDIT Q 6 EXEMPTION 99 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 AND BILLING: L❑ II.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTSNAME(PRINTED 6 SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# F LOCA ON CODE -OPTIONAL CENSUS T`ACT# -OPTIONAL aUPVR-DISTRICT CODE -OPTIONAL �/ S I THIS F RM MUST BE ACCOMPANIED BY AT LEAST(�1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OFSISITE'INFORMATION ONLY. FORM A(5.91) FORW33A3 e H mss '-0 t�)