BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

I OyOVa � STATE OF CALIFORNIA ��' .0 STATE WATER RESOURCES CONTROL BOARD A„� a UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE °'��oR+" MARK ONLY t NEW PERMIT O 3 RENEWAL PERMIT E:] 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE ONE ITEM 0 2 INTERIM PERMIT Q d AMENDED PERMIT O S TEMPORARY SITE CLOSURE t)O I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OSA OR FACILITY NAME NAME OF OPERATOR ADDRESS 1 - - -- NEAREST OSS STREET PARCEL#[OPTIONAL) CITY NAME Ta1F STATE ZIP CODE SITE PHONE a WITH AREA CODE /vIt)_ CAg5tV - n6o r 1Nq RO 0TE O CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCA-AGENCY COUNTYAGENCY• O STATE-AGENCY O FEIIERALAGENCY• If owner d UST is a public agency.oonplete the idloWing:name of Supervisor A division,section,w office Which operates the UST TYPE OF BUSINESSt GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN a OF TANKS AT SITE E.P.A. 1.D.a(cptlnwq RESERVATION 72 3 FARM a PROCESSOR Q 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(UST,FIRST) PHONE a WITH AREA CODE "— 3 NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION bwpl A"Orr- MAILING OR STREET ADDRESS ✓box bb*cata Q INDIVIDUAL ED LOCAL-AGENCY Q STATE-AGENCY .O. �7K L.vZw CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL#GENCY CIT'NAME STATE ZIP CODE PHONE#WITH AREA CODE a CA4� c6o III. TANK OWNER INFORMATION-(MUST BE COMPLETED) 7_413 NAME OF OWNER CARE OF ADDRESS INFORMATION c..- ^S MAILINOORSTREET/A-DDRES ✓box b indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY L g- ElTG C CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY El FEDERAL-AGENCY CITY NAME 9TATE ZIP CODE PHONE*WITH AREA CODE Gp4l= % �t7 ) -D 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 BECOMPLETED)—IDENTIFY THE METHOD(S) USED ✓ bosbadbes O f SELF-INSURED E-1 2 GUARANTEE O 3 INSURANCE O A SURETY BOND 5 LETTEROFCREW 0&EXEMPTION IS 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 13OX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II.f�d In.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY* mF LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPV -DISTRICT CODE -OPTIONAL Z 3 • 3r THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORMS,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM Wr -HE LOCAL AGENCY IMPLEMENTING THE UNDERGROUN! )RAGE TANK REGULATIONS FORM A13f33) I FOR0033AA7 'Y