BILLING - Laserfiche WebLink

Home Browse Search

f � STATE OF CALIFORNIA - r •• o STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORWA - � COMPLETE THIS FORM FOR EACH FACILITY/SITE �nl it p�Nr MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL SIT ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA O FACILITY NAME � `T- - NAME OF OPERATOR ADDRESS fes'- J6 NEAREST CROSS STREE PARCEL#(OPTIONAL) CITY NAME r STATE ZIP CODE SIT�PHONE#WITH AREA CODE CA Gf) ✓BOX EDIrORPORATION ] INDIVIDUAL ]PARTNERSHIP TO INDICATE ]LOCAL-AGENCY ] CCUNTY•AGENCY' ] STATE-AGENCY' ] FEDERAL-AGENCY' 'If owner of UST is a public agency, p g DISTRICTS p g rxy,com fele the 1ellawn:name of s eMser oI division,section or office which operates the UST TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓1F INDIAN #OF TANKS AT SITE �e;wc �00 0 3 FARM Q 4 PROCESSOR Q 5 OTHER RESERVATION OR TRUST LANDS e EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional ;A DAYS: �4ME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FI -/ �- g_ FIRST) PHONE#WITH AREA CODE q 14 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA�CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE tvl r t Ill. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFOR a �S MAILING OR STREET ADDRESS ✓ box foudcale f'] �/ © INDIVIDUAL [] LOCAL-AGENCY (_] STATE-AGENCY ` 4��4J L7GCORPORATION 0 PARTNERSHIP COUNTY-AGENCY CITY NAME C FEDERAL-AGENCY STATE ZIP CO PHONE#WITH AREA CODE eX .5;?b� III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OFNER CARE OF ADDRESS INFORMATION I 7 MAILING OR STREET ADDRESS 04W to vhdir4 I ate,_..�� ED INDIVIDUAL LOCAL-AGENCY ] STATE-AGENCY L�CORPORATiON [= PARTNERSHIP COUNTY-AGENCY ] FEDERAL-AGENCY CITY NAME - STAjI;; ZIP CODE PHONE#WITH AREA CODE 674 `�Za IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate t SELF-INSURED l] 2 GUARANTEE ]3 INSURANCE ] 4 SURETYBOND ]5 LETTER OF CREDIT ]6 EXEMPTION i]7 STATEFUND E]6 STATE FUND&CHIEF FINANCIAL OFFICER LETTER ]9 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 or 11 is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: r.= 11.0 nr. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE SEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S LE DATE MONTHtDAY/YEAR r � � z LOCAL AGENCY USE ONLY ND COUNTY# JURISDICTION# FACILITY# �v E �� D 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 1S A CHANGE OF SITE INFORMATION ONLY. FORMA(6-95) OWNER MUST FILE THIS F041TH THE LOCAL AGENCY IMPLEMENTING THE UNDERG10D STORAGE TANK REGULATIONS