BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATEOFCAUFORTIIA io STATE WATER RESOURCES CONTROL BOARD ' UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOS ITE ONE REM 2 INTERIM PERMIT 71 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE : I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS 'n NEAREST CROSS STREET PARCEL#(OPTIONAL) CITU NAME STATE ZIP CODE / SITE PHONE i WITH AREA CODE CA ✓ BOX TO INDICATE CORPORATION f� INDIVIDUAL f�PARTNERSHIP Q LOCAL AGENCY 0 COUNTY-AGENCY' [:D STATE AGENCY' Q FEDEML-AGENCY' DISTRICTS' II mner d UST Is a public agency,complete the following:name of Supervisor of dIvI ,section,or office which operates the UST TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR R SERVATTION SOF TANKB AT SITE E.P.A. 1.D.i(apiicoaQ 0 3 FARM O 4 PROCESSOR 0 6 OTHER OR TRUST LANDS J EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAMECARE OF ADDRESS INPO MATION - ry�,r t. Lu/ i MAILING OR STREET ADDRESS ✓ Ooxbindkme Q INDIVIDUAL I1 LOCAL-AGENCY STATE-AGENCY CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDEIULAGENCY CITY NA/ME STATE ZIP CODE / PHONE It WITH AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box b WbaN INDIVIDUAL LOCAL-AGENCY STATE-AGENCY CORPORATION O PARTNERSHIP 0 COUNTY AGENCY 0 FEDERAL-AGENCY CITY NAME ZIP— F7D4 PHONE S WITH AREA CODE I IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HOF4_4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓boa b MAicale 1 SELF-INSURED [__1 2 GUARANTEE Q 3 INSURANCE 0 4 SURETY BOND D 5 LETTEROFCREDIT =6 EXEMPTION 97 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. CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[=] 11.[::] III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAM E(PRINTED B SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNT JURISDICTION# FACILITY# _ LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIONAL SUI-DISTRICT CODE -OPTIONAL 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 WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORMA(393) FOR0003Ali7 0 0