BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A ro COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ t NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS } /yam^ ��/7 ��•-j �./.� NEAREST GROSS STREET _/t-.,.p PAflCE1#IOPTIONAq htv CITY NAME STATE ZIP O_DE �, SITE PHONE#WITH AREA CODE 41 reg tri CA V � D :b ✓ BOX L�j CORPORATION INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY [:1 COUNTY-AGENCY' Q STATE-AGENCYFEDERAL-AGENCY' TO INDICATE DISTRICTS ' Hamer of UST is a public agency,camplele the folbwing:lame of supernsorol dWew,section or office whits operates the UST TYPE OF O ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) BUSINESS t GASSTATION ❑ 2 DISTRIBUTOR RESERVATION Q 3 FARM Q 4 PROCESSOR I❑ 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) PONE#WITH AREA CODE '1412 1111 X NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME .x� CARE OF ADDRESS I NFORMATION EET ADDRESS P� ✓ boxtoafxale INDIVIDUAL 0LOCAL-AGENCY I� STATE-AGENGY TRAILING OR STR ^E .iV.0 / p /P- 0 CORPORATION O PARTNERSHIP = COUNTY-AGENCY ED FEDERAL-AGENCY CITY NAME C S�� ZIP CODE PHONE N W ��D _ C III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER pay ESS,,� CARE OF ADDRESS INFORMATION MANNG OR STREET ADDR ✓ boxto uWvala OINDIVIWAL ,LOCAL-AGENCY STATE-AGENCY Q CORPORATION = PARTNERSHIP Q COUNTY-AGENCY O 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 44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indrate t SELF-INSURED O 2 GUARANTEE O 3 INSURANCE =4 SURETY BOND =5 LETTEROFCREDR O 6 EXEMPTION 0 7 STATE FUND O6 STATE FUND&CHIEF FINANCIAL OFFICER LETTER 09 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I o`rr 1I.is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.Ifni III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY T rl COUNTY# JURISDICTION# FACILITY# m LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 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 FORPV THE LOCAL AGENCY IMPLEMENTING THE UNDERGR*TORAGE TANK REGULATIONS ,lv{vRM A(6-95)