BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE 3' MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL If(OPTIONAL) 4(// CITY NAME�C l � ST ZIP CODE SITE NE X AREA CODE D STATE ZIP ' �fl �� Q ✓BOX Q CORPORATION INDIVIDUALPARTNERSHIP E::] LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCY' FEDERAL-AGENCY' TO INDICATE DISTRICTS 4 owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST TYPE OF BUSINESS GAS STATION ❑ 2 DISTRIBUTOR O ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.If(optional) RESERVATION Q 3 FARM a 4 PROCESSOR = 5 OTHER OR TRUST LANDS: MERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FI T) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 0 - 3 4-�5- NIGHTS: NAME(LAST,FIRS PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFO MATION•(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL Q LOCAL-AGENCY (] STATE-AGENCY Q CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL Q LOCAL-AGENCY (] STATE-AGENCY O CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE X WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT BER-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 1 SELF-INSURED = 2 GUARANTEE =3 INSURANCE 0 4 SURETY BOND = 5 LETTER OF CREDIT =6 EXEMPTION = 7 STATE FUND 0 8 STATE FUND S CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM ED 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will b 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.❑ III.❑ 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 8 SIGNATURE) TANK OWNER'S TITLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY N 1 h ri S COUNTY# JURISDICTION# FACILITY# ❑ I A I S LOCATION CODE -OPTIONAL CENSUS TRACT X •OPTiONA SUPVISOR-DISTRICT CODE PTIONAL C) -131 8 � 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 FORF- rH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO"'T STORAGE TANK REGULATIONS FORMA(6-95)