BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A COMPLETE THIS FORM FOR EACH FAOLITYISITE YAIB(ONLY t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ e AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILTTYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR FAC15 NAME E OF OP�E ATOR p - C. # NAM �TRLAPD CfJ ADDRESS NEAREST CROSS STREET FARCELa(OPTIONAU * Jl 504D 10 vTr � RAW- CITY NAME STATE ZIP SITE PHONE a WITH AREA CODE va CA v 1 �IISs-3o4� ✓BD% PORATNON INDIVIDUAL O PARTNERSHIP O LOCALM3ENOY Q COUNTY-AGENCY' O STATE-AGENCY' O FEOEIML#OENCY' TO IN y__" DISTRICTS' A owner of UST M a public agency.em,pNMe the fallowing:name of SupeMwr of ewbbn,section,or office which opNates the UST TYPE OF BUSINESS aW 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ R MIFF INNDIIAAN ON a OF TANKS AT SITE I E.P.A. I.D.0(q7V&* 0 3 FARM D a PROCESSOR Q 6 OTHER OR TRUST LANDS 3 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIR PHONE a WITH AREA CODE LE1A�ts c 5 0 �- 2 u I - 3- Z-71I N SS NAME(LAST.FIRST)� PHONE�E0 WITHA A ODE N S: NAME LAST FI T)" —1 51OPH0 NTH AREA CODEV 3-Z7It II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAMESSORMATIO A RN �ou7N 1...4A� CARE OF IIq MAILING OR STREET ADDRESS 1�yI �.,/ ✓Im bYdlpM � INDIVIDUAL � LOCAL-AGENCY I�STATE AGENCY Sv2 : y> HAk r�0 �'/C�ORPORATION =1 PARTNERSHIP 0 CCWUN-TYAGENCYY O FEDEML#GENCY CITU NAME Hsi-,.�1"' bfJ HREA CODE sTCT ZIP �C38 P�HONE I jT 1(O� T • III. TANK OWNER INFORMATION-(MUST BE COMPLETED) Z'11t NAME OF OWy 5F.RR� CAREOFADDRE INFORMIT11N �4 MAILING OR STREET DRESS 1 ✓ hw binllcels INDIVIDUAL 0 LOCAL-AGENCY Gt7.L d r � O STATE-AGENCY Sb2.b � *34b �COflPOflATON 0 PARTNERSHIP � FEDERAL-AGENCY CITY NAME !y u STA ZIP COBE PHONE a ATH R"CODE 9S6 sw 4&75-2--711 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓ Im bYdkate O 1SELF-INSURED 0 2 GUARANTEE 1J 3 INSURANCE O 5 LETTEROFCREOIT 0 6 EXEMPTION �9B OTHER O I SURETY BOND V1. 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: I.❑ II.�,. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED 6 SIGNED) OWNER'S TITLE DATE M THIDAYNEAR T c,, L I I A196 LOCAL AGENCY USE ON Y COUNTY It DICTION At FACILrrY t LOCATION CODE -OPTIONAL CENSUS TRACTa -OPTIONAL SUPVLROR-DISTRICT CODE -OPl'AOALAL THIS FORM MUST BE ACCOMPANIED BY AT T(1)OR MORE PERMIT APPLICATION- FORM B,UNLE 'IS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORPPMrH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROMW STORAGE TANK REGULATIONS FORMA(3931 fGRONMA]