BILLING - Laserfiche WebLink

Home Browse Search

• • STATE OF CALIFORNIA a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EAC ACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) O DBA OR FACILITY NAME NAMEOFOPERATOR /� IVOYe �+ S Uro r /Pena 1{vuf/n ADDRESS _ NEAREST CROSS STREET PARCEL#(OPT ONA �- CITYNAME ST TE ZIP CODE SITE PHONE#WITH AREA CODE A7 95-d-0 9/6 -'fYd _V7_; ✓ eox TOINDICATE ORPORATION 0 INDIVIDUAL D PARTNERSHIP Q LOCAL-AGENCY [71 COUNTY-AGENCY Q STATE-AGENCY O FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR / IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) Q 3 FARM ❑ 4 PROCESSOR 5 OTHER OOR TRUSTRESERLATION ANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) , PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) x ie j/6- vw-V73 -SD d"412 NIGHTS: NAME(LAST,FIRST) HONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION J;_ yr o fi MAILING ORSTREET ADDRESS // , ✓ box biMicale INDIVIDUAL O LOCAbAGENCY O STATE-AGENCY �A sTi �Q O CORPORATION O PARTNERSHIP - O COUNTY AGENCV Q FEDERAL-AGENCY CITY NAME L STATE ZIP CODE PHONE#WITH AREA CODE Sam ,Y'(J 9 sal�' 7 9 fiv K III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION G MAILING OR STREET ADDRESS ✓ box bindkale 0 INDIVIDUAL D LOCAL-AGENCY I-STATE-AGENCY CORPORATION O PARTNERSHIP O COUNTY-AGENCY t� FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 - D 3 $ a (o V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE 0D(S) USED ✓box m indicate 1 SELF-INSURED [__12 GUARANTEE 3 INSURANCE 5 LETrEROFCREDIT 0 6 EXEMPTION 99 OTHER O 4 SURETY BOND VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is the CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 4 A. VEE 71) �] a s LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPT/ONAL ! 3610 3 dL THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION• FORM Bt UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY, FORM A(5-91) FOROMM5