BILLING - Laserfiche WebLink

Home Browse Search

• STATE OF CALIFORNIA W 4. STATE WATER RESOURCES CONTROL BOARD _ UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH PCILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 010- I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR h ADDAESS #s NE RE TCROSSS. EET PARCEL#(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHO14E I WITH AREA CODE 0 G CA L97,J5,A Q eOX TOINDICATE [--1 CORPORATION INDIVIDUAL Q PARTNERSHIP 0 LOCAL-AGENCY Q COUNTY-AGENCY D STATE AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR / ❑ RESERVATION✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) Z' ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER pq TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAV : NAME(LAST.FIRST) PHOVE#WITH AREA CODE DAYS: NAME(LAST,FIRST) D I NIGHTS: NAME(LAST,FIRST) I PHONE#WITH AREA CODE I NIGHTS: NAME(LAST,FIRST) I r Z I II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME �/ �y CARE OF ADDRESS INFORMATION VV . V � MAILI GORSTREET DRES ✓ box la lMkate = INDIVIDUAL I- LOCAL-AGENCY 0 STATEAGENCY '33 # 0 CORPORATION 0 PARTNERSHIP = COUNrYAGENCY E-1 FEDERAL-AGENCY CITY NAME STATE ZIP CODE P ONE#WI AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) /`'/,[J►• 9:2?a- L7 0-7 5-3 NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STRE TADDR S ,(J./ y.,��,( ✓ box WMkale 0INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY W /W]� I CORPORATION 0 PARTNERSHIP COUNTY-AGENCY E-3 FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION LIST �STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ F4174 - r�✓1.__I�L�"l I� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box a Indbale L-1 I SELF-INSURED O 2 GUARANTEE E 3 1 URANCE 04 SURETY BOND 5 LETTEfl OF CREDIT O 6 EXEMPnON gg 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 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 MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FAF,A� # j � _�� d LOCATIDN- D -OPTIONAL CENSUS TRACT# -OPT/DNA SUPVISOR-DISTRICT CO -OPTIONAL © t THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) FQ9W33A5