Laserfiche WebLink
t6pUR <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR E2 FACILITY/SITE <br /> MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED ST <br /> ONE ITEM E�j 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR F/{tn IaJAME 588 NAME OF OPERATOR <br /> ((JJ r Daniell Eppier I Mang Lane 78 <br /> ADDIWI W. March Lane NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 1f[j I-Warch Lane <br /> CITLfVAMF STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA 95207 209/473-7337 <br /> BOXOCAL-AGENCY,�y L <br /> TO INDICATE INCORPORATION I]INDIVIDUAL ] PARTNERSHIP ] DISTRICTS' COUNTY-AGENCY' (]STATE-AGENCY' FEDERAL-AGENCY' <br /> If owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR ] RESERVNDDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> ] 3 FARM 4 PROCESSOR ] 5 OTHER OR TRUST LANDS 3 CAD582057432 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY$: NA ASTr FIRST`.any Lane <br /> 76 1DLLLtL! <br /> PHONE� AEi�, Q&7 DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> L WWt*OT�I IVf�rCh Lane 78 PHONE# ATH AR C-QD�__ NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME Union OHI Company of CA,dba Unocal CARE OF ADDRESS INFORMATION <br /> MAILINrP.O. Bob((ORSTBEET S ✓ boxbindicate ] INDIVIDUAL ] LOCAL-AGENCY ]STATE-AGENCY <br /> CORPORATION = PARTNERSHIP =COUNTY-AGENCY = FEDERAL-AGENCY <br /> CIN N�tE�Ana STATE 21P CODE 927W5,76 PHC�Fy 41(VIT i <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> N OF O CARE OF ADDRESS INFORMATION <br /> ` nlon"&7Company of California,dba Unocal Environmental Compliance <br /> MAILING OR STREET ADDRESS ✓ box to indicate E::] INDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY <br /> P.O. BOX 2`378 =CORPORATION i] PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE#WITH AREA CODE <br /> Santa Ana CA 92795-2358 (714)4284 <br /> 684 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4]4-]- f 0 5 7 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 2 GUARANTEE ] 3 INSURANCE (]4 SURETY BOND <br /> ] 5 LETTEROFCREDIT 6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.= II.E III.EX <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED 8 SIGNED) OWNER'S TITLE DATE MONTH/ YNEAR <br /> 13iwo - ,V/ S -(rl0 f'�-1�N Co YN�Ila �i <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE-OPTIONAL O <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFOR ON ONLY. <br /> FORMA(3193) <br /> OWNER MUST FILE THIS FOW THE LOCAL AGENCY IMPLEMENTING THE UNDERGR�STORAGE TANK REGULATIONS <br /> FOR0033A41 <br /> 7 <br />