BILLING - Laserfiche WebLink

Home Browse Search

• 'y000w e9 STATE OF CALIFORNIA c `i STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A OPM P COMPLETE THIS FORM FOR EACH F CILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL E ONE ITEM ❑ 2 INTERIM PERMIT ❑ # AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA ORRwr. NAME NAME OF OPERATOR C7� ADDREgS NEAREST CROSS STREET PARCELp OPTIONAL CITY NAME STATE ZIP CODEPH E W H A EA CODS Goo T' CA '73�v 1Z�� £X!� I/ BOX TO INDICATE D CORPORATION D INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY D STATE-AGENCY 0 FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 3 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) RESERVATION 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,F�ST) HONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) P2 /ten Df�/'• �w� -5�`l- 35 NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME Y �F. GLti47' CARE OF ADDRESS INFORMATION MAILING OR STREEIrT'AD/ORES ✓ box blMlrale O INDIVIDUAL DCAL-AGENCY D STATE-AGENCY ✓T� ' I�CORPORATION 0 PARTNERSHIP [-I COUNTY AGENCY FEDERAL-AGENCY CITU NA✓✓ STAT ZIP CODEPHONE#WITAI AREA CODE III. TANK OWNER INFORMATION•(MUST BE COMPLETED) KL 5 NAME OF OWNS . CARE OF ADDRESS INFORMATION Gam/ Y c7� G o MAILING OR STREET ADDR SS / ✓ box blMbate INDIVIDUAL L-A AGENCY O STATE-AGENCY 22 �• �/� / —• 0 CORPORATION 0 PARTNERSHIP = COUNTY-AGENCY (] FEDERALAGENCY CITY.NAME_ STATE ZIP CO; /p PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323--9555 if questions arise. TY(TK) HQ [4-F4-]- V. PETROLEUM UST FINANCIAL RESPONSIBILITY• (MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box blMbate O I SELF INSURED L—1 2 GUARANTEE 0 3 INSURANCE 1 SURETY BONG 5 LETTEROFCREDIT =6 EXEMPTION O W 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 APPLICANTS NAME(PR IN TED&S IGNATURE) APPLICANTS TITLE DATE MONTHIDAYIYEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION At FACILITY# 7 G�P�z LOCATIONCODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUS (STRICT CODE -OPTIONAL oz__ r /fib g� THIS FORM MUST BE ACCOMPANIED BY AT-? INFORMATION T LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A Cl NGE OF SITE INFOONLY. FORMA(5-91) IIID FORoo33AL