BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

Af STATE OF CALIFORNIA .. � STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE ^"'f MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL BE E ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION IIt ADDRESS-(MUST BE COMPLETED) "Q�9 DBA OR FACILITY NAME NAME OF OPERATOR ADDRESSNEAREST CROSS STREET PARCEL#(OPTONAU 22& fi, {J(— eJ CITY A}E STATE ZIP CODE 317E PHONE WITH AREA CODE S�—W� LF-- CA �Zo2 H TOINDICATE O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY NCY UNTYAGENCY' O STATE-AGENCY' 0 FEDERAL-AGENCY DISTRICTS 'If owner of UST Is a public ago*,complete the following:name of Supervisor of division.section,or oflice which operates the UST TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ,/ IF INDIAN 17TANKS TANKS AT SITE .P.EA. I.D.#(APOOV180 RESERVATION E= 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE 4 WITHAREA CQDE DAYS: NAME(LAST.FIRST PHONE N WITH AREA CODE 0 Men 20 NIGHTS: NAME(LAST,FIRST) PHONE# ITH AR(/EaAOCCO/DE NIG`HI'TSS:: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE ( 9'<7- l II y II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAM RE OF CAADDflESS IyFOflMATION MAIkORET ESS ✓box b Wkab (� INDIVIDUAL O LOCAL-AGENCY' Q STATEAGENCY CT— O CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITU NAME STA ZIP CODE PHONE#WITH AREA CODE c zaz y�g 33f III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF POOR 3INFORMATION 4A00 if- k MAILINGOR STREET ADDRESS ✓box bindkate � INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY CORPORATION = PARTNERSHIP COUNTYAGENCY 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 F4_F4- - V. PETROLEUM UST FINANCIAL,KSPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bindkale L11001-1 SEURNSURED O 2 GUARANTEE O 3 INSURANCE 0 A SURETY BOND O 5 LETTER OF CREDIT O 6 EXEMPTION O OP 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. FCHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II III.❑ TH1S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S,A (PRINTED 6 SIGNED) `NER'S TITLE DATE ONT AY/VEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY III - m a a LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR OISTRICT 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 FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FARM Al3/e3) FOR • � _•� 4 Oca]Ali\6Y