SU0007710_SSCRPT - Laserfiche WebLink

Home Browse Search

Rembod STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A -� COMPLETE THIS FORM FOR EACH F [TY/SITE t MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 P Y CLO ED SrT"e ONE ITEM F_� 2 INTERIM PERMIT F_� 4 AMENDED PERMIT (E] 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) - DBA OR FACILITY N! NAME OF OPERATOR i- ADDRESS , d—v NEAREST CROSS STREET PARCEL#(OPTIONAL) . . CITY NAME STATE ZIP CODE / SITE PHONE A WITH AREA CODE CA b _ I/ BOX TOINOICATE Q CORPORATION Q INDIVIDUAL [__1 PAR RSHIP Q LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS = GAS STATION 2 DISTRIBUTOR Q ./ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) RESERVATION Q 3 FARM Q 4 PROCESSOR 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) PHOeE_tYdTx AREA r.0DF NIGHTS; NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE;WITH ARE CODE Il. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bindkate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxtoirdicale Q INDIVIDUAL Q LOCAL-AGENCY `t]STATE-AGENCY Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE 7i� WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 - „ / �� V, PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST/B/ O LMP ETED)—IDENTIFY THE METHOD(S) USED ✓ box 9)hdicate Q 1 SELF INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q 5 LETTEROFCREDR 6 EXEMPTION Q 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= IL F-1 111,a THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE MONTH/DAYlY LOCAL AGENCY USE ONLY j _ COUNTY# JURISDICTION# FACILITY# ml --r1pw1)0j LOCATION 1D -OPTIONAL CENSUS TRA -_QPTIONA1. SUPVISOR-DISTRICT COPE - PTIONAL THIS FORM MUST BE ACCOMPANIED 13Y At LEAST(1)OR MORE PERMIT APPLICATION- FORM B,U LESS THIS IS A CHA OF SITE INFORMATION ONLY, FORM A(5-91) FOR0033A.5