COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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• , �houncta STATE OF CALIFORNIA Ae -��•' cO? STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A `a COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR 5 _ Co G ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CA o GS - .30 � ✓BOX O CORPORATION D INDIVIDUAL PARTNERSHIP LOCAL•AGENCYCOUNTY•AGENCY' STATE-AGENCY' a FEDERAL-AGENCY' TO INDICATE DISTRICTS .�6 _ ff owner of UST is a public agency,complete the following.name of supervisor of division,sedion or office which operates the UST N C �1U TYPE OF BUSINESS a 1 GAS STATION 0 2 DISTRIBUTOR ✓IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION 0 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS ,if-M4GENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAS ,FI PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 2 NIGHTS: NAME(LAST,FIRS ONE#WITH AREA CODE( NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE _ L Cv — 0 `t- II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATI A MAILING OR STREET ADD ESS ✓ box to indicate Q INDIVI ,0{LOCAL•AGENCY STATE-AGENCY (]CORPORATION PAR Tt HIP Y`I COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE w HONE#WITH AREA CODE oc L 5 2V loci III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION 5 J \ a. MAILING OR STREET ADD ESS ✓ box to indicate = INLjIVIDUAL LOCAL-AGENCY =STATE-AGENCY =CORPORATION 0 P ERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE C L0 f 5 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-.,669y if questions arise. TY(TK) HQ F414]- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIkTHE METHOD(S) USED ✓box to indicate 1 SELF-INSURED =2 GUARANTEE rZ3 INSURANCE =4 SURETY BOND =5 LETTEkbF CREDIT 0 6 EXEMPTION 0 7 STATE FUND 8 STATE FUND 8 CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND 8 CERTIFICATE OF DEPOSIT 10 LOCAL GOVT.MECHANISM = 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing Will be sen&the tank owner unless box I or 111 its checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING-" I. It.I X I 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF KNOWLEDGE,IS TRUE AND CORRECT P OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAY/YEAR Ga- �-- Wy tE -u R o E 8 t o LOCAL AGENCY USE ONLY , COUNTY# JURISDICTION# FACILITY# JIU 0 51 I LOCATION CODE - PTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 3 KI LOCATION CODE -fPTIONAL 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 FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO�STORAGE TANK REGULATIONS FORMA(6-95)