COMPLIANCE INFO_1999-2007 - Laserfiche WebLink

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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD W dam, a ;... UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT r-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY C ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE - I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) .» DBA OR FACILITY NA E NAME OF OPERATOR C;gF_Vl'0W IISif-3 Vs ADDRESS5 I 6 14� N,) > At4REE SS STREET PA iCEL#(OPTIONAL CITY NAME ,` ST CA 9.5 ZCODE S" PHONE#WITH AREA CODE ZIP ✓ BOX CORPORATION Q INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' �S'TBAATEE--AGENCY' Q 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 1 GAS STATION 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION " 3 FARM Q 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) PHONE#WITH AREA CODE Ire NOT YeT Im$rhUWe.V"_ WTEWA+ (900) -1z 357-9 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Cftpo Imo"" LINA $� 231-a&23 D23 II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME l YC t (�,.. CARE OF ADDRESS INFORMATION j MAILING OR STREET ADDRESS i ` ' �✓ bbo"z to indicate INDIVIDUAL 0 LOCAL-AGENCY = STATE-AGENCY L/�`5 �`,•Y I 3�� U CORPORATION PARTNERSHIP = COUNTY-AGENCY = FEDERAL-AGENCY CIN NAME .r ZIP CODE PHONE#WITH AREA CODE G am" z5 g112.- III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CMW ITSS INION FMATr% MAILING OR STREET??DRESS ✓ to indicate =INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY 1 ' Vr 6� CORPORATION =PARTNERSHIP = COUNTY-AGENCY = FEDERAL-AGENCY CITY NAME STYE, ZIP CODE 7 0HONE#2.5) AREA t2-CO IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER/-Call(916)322-9669 if questions arise, TY(TK) HQ F4—F41- -1013 1 15 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED Fox to indicate 0 1.SELF-INSURED =2 GUARANTEE 0 3 INSURANCE =4 SURETY BOND 0 5 LETTER OF CREDIT =6 EXEMPTION 0 7 STATE FUND 8 STATE RIND&CHIEF FINANCIAL OFFICER LETTER 0 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.F--j it. III Ioewr THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT pip �I l�NTED&SIGNATURE) TANK 01 f3 I'S TITLE DATE =Ef in, LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# m k5 P IS' 13sa � zl LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST B ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNI MUST FILE THIS FORM t fHE LOCAL AGENCY IMPLEMENTING THE UNDERGROU =RAGE TANK REGULATIONS FORM A(6-95)