COMPLIANCE INFO_1986-1999 - Laserfiche WebLink

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Pea°""c ra c STATE OF CALIFORNIA STATE WATER RESOURCES'CONTROL BOARD W , a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e COMPLETE THIS FORM FOR EACH FACILITY/SITE l� 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 I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DPA OR FACILITY NAME NAME OF OPERATOR -IUB /" pN u ADDRESS / NEAREST CROSS STREET PARCEL#(OPTIONAL) iL) 4 d� if 'Irl/SST i TY NAME STATE ZIP CODESITE PHONE#WITH AREA CODE 1'' • kTD/J CA q_ is _7" o?Q - :S9- ;;?3q ✓BOX l]CORPORATION l= INDIVIDUAL ZPARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' D STATE-AGENCYFEDERAL-AGENCY' TO INDICATE DISTRICTS If 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 I—Jl t GAS STATION 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. 1.0.#(optional) 9A RESERVATION 0 3 FARM 0 4 PROCESSOR Q 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) PHONE#WITH AREA CODE GOC-Jid;Ao20 -.5 w ' 611A 20 -47 3.17-cl?3 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE e- 1111. II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFp) NAME CARE OF ADDRESS INFORMATION �'L LDe /�s L/7/L16 elvD. MAILING /OR STREET A RENS ,/ ✓ bcx to r=a O INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY ,' 3® re,4e 4(/f =CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE A Tec 4 9533 C-4 �33`rL;:?e9 :k3--%Vo 3 III. TANK OWNER 'I'NFORMATIO�N,/-(MU-ST BE COMPLETED) RMATION qct /Q y {.7 q AILING ET D SS �'/P J/ ✓ boxto indicate /\� INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY ��c /, / V =CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME �A STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUA IZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓box to indicate 0 1 SELF-INSURED = 2 GUARANTEE =3 INSURANCE 0 4 SURETY BOND Q 5 LETTER OF CREDIT =6 EXEMPTION [__1 7 STATE FUND O 8 STATE FUND 8 CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.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.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDE ENALTY ERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE TANKOWNER'S TITLE DATE MONTH YNEAR 9 r "i�� w LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# I I 10 tW LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL ._ I 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 FORjW THE LOCAL AGENCY IMPLEMENTING THE UNDERGR0 STORAGE TANK REGULATIONS FORMA(6.95)