COMPLIANCE INFO_1986-2002 - Laserfiche WebLink

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• � ounces STATE OF CALIFORNIA Pis o0 AP ,. STATE WATER RESOURCES CONTROL BOARD W dam, v UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE '* .on* MARK ONLY D 1 NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED.SITE ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR A(>1 r IG l41k) - MA2.7- r--P_ C_ 5A (Z2AL05/A ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 49I( PAc,rr- Icc A\/E . 14-oSC-n"a2rel LASE CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE 5rnu<-TbAj CA . CA 95207 ✓BOX rV CORPORATION O INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY 17-71 COUNTY-AGENCY' STATE-AGENCY' 0 FEDERAL-AGENCY' TO INDICATE DISTRICTS It 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 F)q 1 GAS STATION 2 DISTRIBUTOR = ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION 3 FARM a 4 PROCESSOR = 5 OTHER OR TRUST LANDS 4 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE Sb�sZk ��n UNC-L- 4_7 ;I5_1/-7 3 P14 15 /",4 Lt4CI 54`73- /7 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE S L4 KW vii i N7 6 P_ S i A C N 4 7-s- 4 L I 7'S_2 Z IL PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFD) NAME CARE OF ADDRESS INFORMATION e, F\-rJt-� L 5 A(2.AC1al A 5' k R_A01A ANT• tf�,Q EL, SA(L16,f7,/A MAILING OR STREET ADDRESS ✓ bcx to e=.`X' INDIVIDUAL LOCAL-AGENCY STATE-AGENCY I I A ciI F 55 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE P NE WITH AREA CODE S- Nc*TVAi C-A aisIL 7 716- 73- //7 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate = INDIVIDUAL Q LOCAL-AGENCY 0 STATE-AGENCY ci S(( PA c F I G At/L - [)Z CORPORATION a PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE7!� WITH AREA CODE ,J G4 9's-z v -� IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓box to indicate 0 1 SELF-INSURED = 2 GUARANTEE =3 INSURANCE =4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION 0 7 STATEFUND 8 STATE FUND&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.d 11.= III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNS TITLE DATE MONTHMAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# m LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 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 FORD THE LOCAL AGENCY IMPLEMENTING THE UNDERGR*STORAGE TANK REGULATIONS FORMA(6.95)