BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

• 0 / STATE OF CALIFORNIA :` ,� •• "o STATE WATER RESOURCES CONTROL BOARD T:, I/ UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A s COMPLETE THIS FORM FOR EACH FACILrrYISITE `'t��o•+'' MARK ONLY ❑ l NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY OSED TE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION III ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAMENAMEO OPERATOR 7 _ C-Ic- Cf yj til j WCC ,,- ADDRESS ADDRESS NEARESTp``RlOSS STREET PARCEL#(OPTIONAL) Lc )cus� —" T (A CITY NAME STATE ZIP CODE SITE PHONE s WITH AREA CODE " CA 36G TOININpOX ED CORPORATION 0 INDIVIDUAL =PARTNERSHIP I� DSTRICTS�Y 0 COUNTY-AGENCY' O STATE-AGENCY' Q FEDERAL-AGENCY' If owner of UST Is a public agency,complete the following:nems,of Supervisor of division.seclbn,or office which operates the UST TYPE OF BUSINESS ❑ L GAS STATION ❑ 2 DISTRIBUTOfl ❑ RESEIF I RVATDION a OF TANJKJS SAT SITE E.P.A. I.D.a(gNAnaq ❑ 3 FARM ❑ < PROCESSOR 5 OTHER ORTRUST LANDS v EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-options[ DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE*WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE If. PROPERTY OWNER INFORMATI N• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bmbindio" Q INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY =CORPORATION 0 PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COIL D) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ smbiMicale INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY ORPORATION O PARTNERSHIP Q COUNTY-AGENCY FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(91%THE ons arise. TY(TK) HQ [_4T4_-]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IOD(S) USED ✓fnsbbdkale Of SELF-INSURED (]2 GUARANTEE I�3 INSU CE 0 d SURETY BOND 5 LETrEROFCREDIT D 6 EXEMPTION O 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: I.❑ II.❑ III.❑ THIS FORM RAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED B SIGNED) OWNER'S TITLE DATE MONTWDAWVFAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY• 3m1 i y 17 131 LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL aUPVISOR DISTRICT CODE -OPTIONAL 5 -zze — 313 - THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INF RMATION 01 OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULA / FORMA(3193) . ��\TC�oD3 p]