BILLING - Laserfiche WebLink

Home Browse Search

• • STATEOFCAUFORWA �� se STATE WATER RESOURCES CONTROL BOARD = ' UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A , COMPLETE THIS FORM FOR EACHFACILrTY/SITE C�IVOn"'-. MARK ONLY D f NEW PERMIT3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION 7 PERMANENT- CLOSED SITE ONE REM E:j 2 INTERIM PERMIT ILI 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE U I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DRA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME1 IP CODE SITE PHONE A WITH AREA CODE G01-11_- CA �i2ND ✓ BOX LOCA4AGENCV TO INDICATE O CORPORATION IVIDUAL PARTNERSHIP 0 DISTRICTS' 0 COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL If owner ol UST Is a public agency.COM101e the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS O t GAS STATION = 2 DISTRIBUTOR 0 (oV IF INDIAN 1 ptional)RESERVATION #OF TANKS AT SITE E.P.A. I.D.#(optional) 0 3 FARM � 4 PROCESSOR 5 OTHER OR TRUST LANDS I EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME hAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE �nIT W• Z� —�77� NIGNS: E(LAST,FIRST) PHONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DE II. PROPERTY OWNER INFORMATION- MUST B&COMPLETED) NAME /' CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ OoxnlMkate =414DIVIDUAL 0 LOCAL-AGENCY (] STATE AGENCY CJD r1 T� 0 CORPORATION = PARTNERSHIP COUNTY FEDERAL-AGENCY CITY NAME NAAM( V STAT ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMP ETED) NAME OF OWN CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box b r4E7:1Indicate G DIVIDUAL LOCAL-AGENCY STATE AGENCY G &4� s`- 0 CORPORATION `=\PARTNERSHIP 0 COUNTY-AGENCY E�] FEDERAL AGENCY CITY NAME STATV ZIP CODE Zr, PHONE#WITH AREA CODE L o/0- lam, /V IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 W-L l I V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box or Micale [__1 I SELF INSURED E-1 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND D 5 LETTER OF CREDIT O 6 EXEMPTION O SB 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.❑ 11.E 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED 6 SIGNED) OWNER'S TITLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY a JURISDICTION III FACILITY g >< = 2 LOCATION CODE -OPTIONAL CENSUS TRACT8 -OPTIONAL SUP�ISOR TRICT CODE -OPTIONAL L-%- THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERM ---IT APPLICATION FORM B,UNLESS THIS IS A CHANGE OF SIZE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORD03314417 FORM A(393) • lJ F" t