BILLING - Laserfiche WebLink

Home Browse Search

't • C i STATE OF CAL11R)RWA ' STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A . a COMPLETETHIS FORM FOR EACH FACILITYISITE °"'°""•- MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT �/y�6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOBE ONE REM ❑ 2 INTERIM PERMIT 714 AMENDED PERMIT r❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) OPA OR FACILITY NAME NAME OF OPERATOR / Q!/JN�iT��• ADDRESS / NEAREST CROSS R PMCEL (OPTXINAu W \ CITU NAME // CA ST ZIP D SITE PHONE#WITH AREA CODE OV TOO/ Box E 0 CORPORATION INDIVIDUAL E]PARTNERSHIP I� DLA L.AG NNCY O CoUNTY.AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' •If mner o(UST Is a public agency.°onplete the.following:name of Supervisor of division,section,or ollice which operates the UST IL TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ REBERVADTI AN #OF TAN SITE E.P.A. I.D.#(optimal) E:-] 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional D : NAME( ST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE Wl !v - 35 NIGHTS: NAME(LAST,FIS PHONE#WITHAREACODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE l / // aQ � - II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION eSS a�MAILING OR STR ✓ box binE'cate 0 INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY x �� Q CORPORATION PARTNERSHIP O COUNTY AGENCY Q FEDERAL-AGENCY CITY NAMEr, 1O G STATE 21P CODE PHONIWITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE,COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION �> MAILING OR STREET ADDRESS ✓ hoxbiMk#s [I] INDIVIDUAL 0LOCAL-AGENCY � STATEAGENCY CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F4-K- V. 4- -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box blMbate O 1 SELF-INSURED 0 2 GUARANTEE Q 3 INSURANCE O 4 SURETY BOND D 5 LETTER OF CREDIT 0 6 EXEMPTION 0 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. 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 OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY Ro C Zr' COUNTY �# JURISDICTION# # LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONALe,91 SUPVISOR-�T^ICT �/ iM O 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 FOR0033AA7 FORM A(393)