COMPLIANCE INFO_1987-1998 - Laserfiche WebLink

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rEeou^ cs o STATE OF CALIFORNIA ` Ar ' STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A .� . COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT El 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT F__j 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACT ITY N E NAME OF OPERATOR Fb4i X11 i,1 I kirc161° '70 ADDRESS f NEA ST CROSS STREET PARCEL#(OPTIONAL) ' 14 Easy 1-��n^, ��rL�re� L."An CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE kJ 0y) I CA I5 ✓BOX Ly CORPORATION E:3 INDIVIDUAL E�:] PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY' 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 E5 1 GAS STATION Q 2 DISTRIBUTOR Q ✓IF INDIAN #OF TANKS AT SITE I E.P.A. I.D.#(optional) 0 3 FARM O 4 PROCESSOR RESERVATION 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST)nn,, PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE VJ NIGHTS: NAME( T. 4'1 `' FIRST) PHO #WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Lit S5 - II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME s CARE OF ADDRESS INFORMATION rcl e,s CT �� MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL D LOCAL-AGENCY STATE-AGENCY CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE _ ZIP p72_; "+ MIM50 -7�, M WITHA A CODE III. THANK OWNER INFORMATION-(MUST BE COMPLETED) A� NAME OF OWNERCARE OF ADDRESS INFORMATION i 's Y16. (i MAILING OR STREET ADDRESS /y p✓ boxio indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STjZIP CODNE#WITH AREA CCDE"hpe n ix � �� 4 �� IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ4T4-1101 j -2 1O 7 31 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETYBOND 0 5 LETTEROFCREDIT 0 6 EXEMPTION 0 7 STATE FUND D 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND&CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM 0 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.0 ll.O "' III.�y l THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT � TANK OWNER'S NAME(PFIINTED&SIGNATURE) TANK OWNER'S TITLE DATE I�7MONTH/DAYNEAAR fix TO-440r LOCAL AGENCY 6SE 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 FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(6-95)