BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

• li # `LI • a STII/TE OFCALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A`� COMPLETE THIS FORM FOR EACH ACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR Y ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) O CITY NAME STATE ZIPtyka D SITE PHONE#WITH AREA CODE CA ✓ BOX TOINDICATE (]CORPORATION 0 INDIVIDUAL l= PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY D STATEAGENCY O FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION L] 2 DISTRIBUTOR ❑ ./ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional/ RESERVATION ❑ 3 FARM F-1 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) PHONF 9 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COOP II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓boa 0Micah, O INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY Q CORPORATION O PARTNERSHIP COUNTY-AGENCY [__1 FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE ON-(MUST BE COMPLETED) NAME OF OWNER IE 1 CAR OFA DRESS INFORMATION t J MAILING OR STR TADDREnS h ✓ a bola a O INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY los ORPOSATION [--] PARTNERSHIP =COUNTY-AGENCY FEDERAL-AGENCY CITY NAMEf ZIP CODE PHONE#WITH AREA CODS IV. B STOR EE ACCOUNT NUMB 3 arise. �i 0 TY(TK) HO [CA]- V. PETROLEUM UST FINANCI RESPONSIBILITY- (MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ bDx b indicate LY 1 SELF-INSURED ED 2 GUARANTEE =1 3INSURANCE 4 SURETY BOND =5 LETTER OF CREDIT 0 6 EXEMPTION [--1 93 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 11.❑ 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) APPLICANTS TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION It FACILITY# !I T01 LOCATION CODE -OPTIONAL CENSUS TRAQT# -OPTIONAL SUPVISOR-DISTRICT CODE�TIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(5-91) �.. F��\I