BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

�J 0 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROU0 STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED_SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE�.. I. FACILITY/SITE INFORMATION & ADDRESS - (ML' 3T BE COMPLETED) DBA OR FACILITY NAME ? NAME OF OPERAATQR /h Cis /o `-) v y- ,� / f "I r#e 0 ADDRESS N REST CROSS STREET PARCEL # (OPTIONAL) /92 atd,rt, NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE CITY NAME STATE ZIP CODSI SITE PHONE # WITH AREA CODE qI h/C: CA PHONE p WITH AREA CODE 79S E69/ AD fish ✓ BOX CORPORATION 0 INDIVIDUAL O PARTNERSHIP 0 LOCAL -AGENCY D COUNTY -AGENCY' ❑ STATE -AGENCY' 0 FEDERAL -AGENCY' TO INDICATE DISTRICTS ' H ownerof UST e a public agency, complete the felbwing: iwne of s pemscrol dmson, seclnn or oKce which operates the UST TYPE OF BUSINESS FX 1 GAS STATION ❑ 2 DISTRIBUTOR IF INTDIAN # OF TANS AT SITE E.P.A. I. D #. (optional) REV ION ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRS PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE OAW C N D{+tVr MAILING OR STREET ADDRESS �. �)t/, NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE 70lu6v/V luf,' '4S c, USC'.F /y C7 67-745-66 IL PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION XE V /UM EMC' CJ MAILING OR STREET ADDRESS ✓ box to sdIcate O INDIVIDUAL MAILING OR STREET ADDRESS` ✓ buloindrale O INDIVIDUAL 0 LOCAL -AGENCY O STATE -AGENCY J,, C A / ?5 L b IM CORPORATION O PARTNERSHIP 0 COUNTY -AGENCY 0 FEDERAL -AGENCY CITY NAME PHONE p WITH AREA CODE 79S E69/ STATE ZIP CODE PHONEWITH AREA CODE � r (/;? Cu. 9q� 707 7415-669/ III. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAMEOF OWNER ./ 1 CARE OF ADDRESS INFORMATION FACILITY # XE V /UM EMC' CJ MAILING OR STREET ADDRESS ✓ box to sdIcate O INDIVIDUAL LOCAL -AGENCY 0 STATE -AGENCY �Cj ,1- � � `j Zj CORPORATION = PARTNERSHIP O COUNTY -AGENCY O FEDERAL -AGENCY CITU NAME �,./CL �'� STATE ZIP CODE iZ/o PHONE p WITH AREA CODE 79S E69/ a IV, BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. TY (TK) HQ 4 4 G I S y V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ Wx10 dkab 0 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND 0 5 LETTEROFCREDIT 0 6 EXEMPTION ® T STATEFUND 116 STATE FUND& CHIEF FINANCIAL OFFICER LETTER 09 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT. MECHANISM 099 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: I. ❑ it. S] III. O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME (PRINTED & SIGNATURE) TANK OWNERS TITLE DATE MONTFYDAY/YEAR I , �F l u L l l a pP J�iwxr 6-.4 LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # FACILITY # (vU I L? Z; el LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR -DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF bill, INFUHMAI IUN UNLT. OWNER MUST FILE THIS FORMI THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO10TORAGE TANK REGULATIONS FORMA (6-95)