BILLING 1985-1997 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA • r'"�%....g c�i STATE WATER RESOURCES CONTROL BOARD W d� m o UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A :s _ ,, • itl COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE C I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR a k s� i5irl dA7 ADER�LSS NEAREST CROSS STREET PARCEL It(OPTIONAL) 7M 4a CITYNAPAME STATE ZIP CODE TE PHONE p WITH AREA CODE CA �5Z2� 5vv� Z87�/G2� ✓BOX O CORPORATION ] INDIVIDUAL ]PARTNERSHIP Q LOCAL-AGENCV O COUNTY-AGENCY' ] STATE-AGENCY' (]FEDERAL-AGENCY' TO INDICATEDISTRICTS 'Movmerol USTu a public agency,m 108 the 101101g:name ol supenraorol tlNzbn,section or oHim which memles the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR RE.1 IF INDIAN SERVATION p OF TANKS AT SITE I E.P.A. I.D.X(optional) ❑ 3 FARM ❑ 4 PROCESSOR 0 5 OTHER OR TRUST LANDS I EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIR PHONE X WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE �}pL��vf rx�i.9 /�) ZS7-/627 NIGHTS: NAME(LAST.FIRST) ONEN WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME (Jo ".O�P• v 'D.O CARE OF ADDRESS INFORMATION ✓ boxlo Ldmle MAILING OR STREET ADDRESS/� ED INDIVIDUAL ]LOCAL-AGENCY ] STATE-AGENCY PO Q CORPORATION O PARTNERSHIP [—ICOUNTY-AGENCY0 FEDERAL-AGENCY CITY NAME ;`T55� STATE ZIP COD PONE X WITH AREA CODE ai+K � � G,z3 hos .o ZS ion III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION -"7 - , 17 MAILING OR STREET ADDRESS ✓ boxlo i,S,mla ED INDIVIDUAL LOCAL-AGENCY STATE-AGENCY D ZL�aS i]CORPORATION Q PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY ITV/^NAME STATE ZIPeC�O�D/E/.� PHONE X WITH AREA CODE•\ 0, 0`1 /yidT�✓�_5 kj/D�Tis IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-96691f questions arise. TY(TK) HQ 4 4- - Z ?i V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD($) USED ✓box Mirdimle i] 1 SELF-INSURED -_-12 GUARANTEE ]3 INSURANCE O 4 SURETY BOND E3 5 LETTEROFCREDIT i]6 EXEMPTION L-37 STATEFUND i]a STATE FUND&CHIEF FINANCIAL OFFICER LETTER 09 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCALGOVT.MECHANISM ] 99 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.❑ II.X III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANKOWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE GATE MONTHRJAYNEAR LOCAL AGENCY USE ONLY Ufffl COUNTYp JURISDICTION X FACILITY� Z LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL o/ v 3Zv 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 TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO jrTORAGE TANK REGULATIONS FORM A(6.95)