COMPLIANCE INFO_1995-2004 - Laserfiche WebLink

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�eouR e. STATE OF CALIFORNIA ^e ' STATE WATER RESOURCES CONTROL BOARD a . UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A .. o •C�(If 01�N' AMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY L_ i 1 NEW PERMIT IV3 RENEWAL PERMIT jai 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM J 2 INTERIM PERMIT U 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE a/ I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBLnITY NAME NA_MERATOR f_AD � NE E$TCROS TREET PARCEL#(OPTIONAL) it-It v CITY NAME S TATE ZIP C E SITE PHQNE# TH AREA CODE CA I/ BOX `f TO INDICATE CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION n 2 DISTRIBUTOR ✓ IF INDIAN 1#OF ITS 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) ONE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box bindicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY C]CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE P� III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY (]STATE-AGENCY CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE I IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ [414 i4'Ld � �.41L V. PETROLEUM UST FINANCIA SPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ box to indicate 1 SELF-INSURED r 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND 1 5 LETTEROFCREDIT L—) 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 ecked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. III. THIS FORM,HAS BEEN COMPL6,�TEO UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED 8 SIGNATURE) APPLICANT'S TITLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION C09 TIONAL iCENSUS TRACT# TIO SUPVIS D TRICT ODE P ONAL 1 /1 (no THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B, NI ESS THIS IS A CHANGE OF SITE INFORMATI N ONLY. FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0033A-R6 I