BILLING 1993 - 2004 - Laserfiche WebLink

Home Browse Search

#s low STATE OF CALIFORNIA os G STATE WATER RESOURCES CONTROL BOARD �`"`� e UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A ,.ro COMPLETE THIS FORM FOR EACH FACILITY/SITE I NEW PERMIT D 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION T PERMANENTLY C ED MARK ONLY ONE ITEM 2 INTERIM PERMIT O N AMENDED PERMIT El 6 TEMPORARY SITE CLOSURE � I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) NAME OF OPERA peAO AGILITY NAME a C EA L \ • NEAREST CROSS STREET PARC #(OPTIONAL) ADD ESS �— STAT(/,EA ZIP OOE �� SITE PH NE WITH AREA CODE CITY NAME S S W, BOX 0 CORPORATION - O WONIWAL PARTNERSHIP DISTRICTS�Y COUNTY-AGENCY' Q STATE-AGENCY' FEDERAL-AGENCY' To INDICATE •NNwnNr of UST's a Public agency-1.1Nlha 101bwhg wrna Of Superrisard ONuun,setlanoraNKe whir opeales lheU ✓IF INDIAN XOF TANKS AT 517E I E.P.A. I.D.N(Wtional) TYPE OF BUSINESS Q 1 GAS STATION O 2 DISTRIBUTOR f� gESERVATION Q 3 FARM Q 1 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-0 optional DAYS: NAME(LAST.FIRST) PHONE#WITH-AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADORESSINFORMATION NAME ✓ mxWVX to Q INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY MAILING OR STREET ADDRESS Q CORPORATION O PARTNERSHIP =COUNTY-AGENCY 0 FEDERAL-AGENCY STATE ZIP CODE PHONE N WITH AREA CODE CITY NAME III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CAPE OF ADDRESS INFORMATION NAME OF OWNER ✓ bpxt0vxIiWI8 Q WDIVIDUAL 0 LOCAL-AGENCY lD STATE-AGENCY MAILING OR STREET ADDRESS CORPORATION O PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY STATE ZIP CODE PHONE N WITH AREA CODE CITY NAME IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise, TY(TK) HQ F4-[4--]-F--[—[= V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓0oxroe�Crare O 1 SEIF-INSURED O 2 GUARANTEE O B INSURANCE O A SURETY BOND 1� 5 LSTTEROFCREDR Q 6 E%EMPTION O T STATE FUND I#STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT =110 LOCAL GOVT.MECHANISM O99 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.O II.a 111.O 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 MONTHrDAYNEAR LOCAL AGENCY USE ONLY COUNTY a JURISDICTION a FACILITY a 3r'J LOCATION CODE•OPTIONAL CENSUS 7RACT# -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 FOi' "TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGR(" STORAGE TANK REGULATIONS. FORMA(6-95)