BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

a !r• • f STATE OF CALIFORNIA °a tB STATE WATER RESOURCES CONTROL BOARD �.,� „p; UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A _ ` COMPLETE THIS FORM FOR EACH FACILITYISITE `'coca!" MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 61 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DSA OR FACILITY NAME NAME OF OPERATOR l ADDRESS NEAREST CROSS STREET PARCELa(OPTIINAU 8 300 ✓ /P d 4A- CITY NAME STATE ZIP CODE I SITE PHONE a WITH AREA CODE CA 752! / Z T 10 Np AC TE CORPORATION I� INDIVIDUAL I=PARTNERSHIP I� LOCAL-AGENCYI�COUNTY-AGENCY' ESTATE-AGENCY' O FEDERM.-AGENCY' DISTRICTS' •ff aMa of UST Is a public agency,eonpla,the following:name of Supervisor of dlViebn,section.or office which operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR = / IF INDIAN RESERVATION S OF TANKS AT SITE E.P.A. I.D.a fopnuWA 3 FARM Q 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE Is WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME \\ CARE OF ADDRESS INFORMATION U It C_ iS Hr) MAILING OR STREET ADDRESS `` � ✓bubb�b O INDIVIDUAL Q LOCAL-AGENCY O STATE-AGENCY 2--7 �S ( J9 f�CORPORATION O PARTNERSHIP COUNTY-AGENCY O PEDERALAGENCY CITY NAME STATE ZIPCODE PHONE a WITH AREA CODE III. TANKOWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION .Vc s MAILING OR STREET ADDRESS ✓ bubiMNMs INDIVIDUAL O LOCAL-AGENCY D STATE AGENCY CORPORATION D PARTNERSHIP O COUNTYAGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE 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 METHOD(S) USED •/ hos binA[>r O I SELF INSURED 2 GUARANTEE O 3 INSURANCE O A SURETY BOND 5 LETTER OF CREDIT O 6 EXEMPTION O N 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. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ 11.2T- 111.0 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) OWNERSTRLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY 0/.p /09'VLf6 FI DW 47al COUNTY If JURISDICTION• FACILITY i m = s 61-5 Es LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL SZ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIOtp (393)