BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

�sOUR STATE OF CALIFORNIA :P P dol^ STATE WATER RESOURCES CONTROL BOARD a ., CJ UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A Cil it Uq� COMPLETE THIS FORM FOR EACH FAC ITE MARK ONLY 1 NEW PERMIT a 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMAN CLOS ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR Va//-e Iq ofvv3 ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) U CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE S CA —3 0 c ✓ BOX TO INDICATE E:71 CORPORATIO INDIVIDUAL D PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTORI/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION 0 3 FARM = 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) 14!4 c(" ke( PHONE a WITH AREA rODF NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY (]CORPORATION Q 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 toindicate INDIVIDUAL LOCAL-AGENCY (]STATE-AGENCY 0 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#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 BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box to indicate 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND D 5 LETTER OF CREDIT O 6 EXEMPTION 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.F-11 II.❑ 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 MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# A LL ma, Y d OV LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL t' 3 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ON FORM A(5-91) FOR0033 - c �