BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CAUFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED.S�ITE�, ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �l/ I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) / DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEA ESTCROSS STREET PARCELX(OPTIONAL) �vT�rA1�7 CITY NAME STATE ZIP CODE SITE PHONE X WITH AREA CODE /.49D CA 95P.A1D {Gv9)9413- Z oy / ✓BOX 0 CORPORATION C3 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' STATE-AGENCY' 0 FEDERAL-AGENCY' TO INDICATE DISTRICTS tl owsurd UBT B a pubic agency.comylete Na lollowig:name d supervisor d division,section moBrte v1 ich operates the UST TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATIONIFX OF TANKS AT SITE E.P.A. I.D.X(optional) 0 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) P ONE X W3e AREA CODE DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE �] z,> ��J—ZO/ NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE X WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION A 4r b k� MAILING OR STREET ADDRESS ✓ box lnndntt9 0INDMDUAL 0 LOCAL-AGENCY O STATE-AGENCY 1015 "4,�qp�j r 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODEPHONE X WITH AREACODE od 04 472wz_ oq 9 d13 Zoi/ III. TANK OWNER INFORMATION -(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS , ✓ boxto Ykimte =1 INDIVIDUAL OLOCAL-AGENCY (STATE-AGENCY lR I AtIll OnIf ✓A5 0 CORPORATION O PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATEZIP CODE PH NE X WITH AREA CODE 49r,7 44!:74 04 95;z mom' 9�f3-Zb/ IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓has to indicate I SELF-INSURED 0 2 GUARANTEE 0 31NSURANCE 0 4 SURETY BOND 0 5 LETTEROFCREOIr O 6 EXEMPTION O T STATE FUND B STATE FUND B CHIEF FINANCIAL OFFICER LETTER 09 STATE RIND&CERTIFICATE OF DEPOSIT 010 LOCAL GOVT.MECHANISM 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.❑ it.❑ III. 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 OWNER'S TITLE DATE MONTH/DAWYEAR LOCAL AGENCY USE ONLY tt�� COUNTY X JURISDICTION N FACILITY X LOCATION CODE -OPTIONAL CENSUS TRACTI -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL ?"yo. -gp I 32z, THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM FORMA(695) 16 THE LOCAL AGENCY IMPLEMENTING THE UNDERGROSSTORAGE TANK REGULATIONS