BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EAC ACILTTYISITE MARK ONLY F I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SIT ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAu IS S S TOZ,C .✓ CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE LoI C A OA Z O 33 TO INDICATE D9,CORPORATION I7 INDIVIDUAL 0 PARTNERSHIP L--I LOCAL-AGENCY O COUNTY AGENCY [71 STATE-AGENCY L-1 FEDERAL-AGENCY DISTRICTS TYPEOFBUSINESS O I GASSTATION 2 DISTRIBUTOR 0 RESEIFINDAN RVATION #OF TANKS AT GITE E.P.A. LD.#(apTianap 3 FARM Q 4 PROCESSOR [0-5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) Zc+y 31q 3 X�3 L L6 u LtJ 3 Ne-v9eZ G CnnF NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) j(# L1tWL(—t1 iZ6.m 2-O°I S3CY OS-Oef .9✓aEG S2uE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION R&fAll A e• i+ L IL- MAILING OR STREETADDRESS ✓ box b indicate Tj INDIVIDUAL Q LOCAL-AGENCY STATEAGENCY PO O 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY (] FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE LL)00'D 6210L& C-14 S 2Pct R 7 III. TANK OWNER 160MATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION A-5 A 6UJE- MAILINGORSTREET ADDRESS ✓ box to indicate INDIVIDUAL E-1 LOCAL AGENCY 0 STATE-AGENCY CORPORATION PARTNERSHIP [--] COUNTY-AGENCY O FEDERALAGENCY 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 -EETT I I ' V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bindicale D I SELF-INSURED UARANTEE 0 7 URANCE 0 d SURETY SONO 5 LETTEROFCREDIT Vr6 EXEMPTION 99 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.[-] I.K 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) PPLICANTS TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE E--OPTIONAL CENSUS TRACT* OP�R0 L SUPVISOR-DISTRICT CODE -OPTIONAL �AA+LT/1 sL� THIS FORM MUST BE ACCOMPANIED BY AT LEAST( RE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(S-91) _ FCR0073A5 Ctir~ P.�e