COMPLIANCE INFO_1986-2002 - Laserfiche WebLink

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F `* ky STATE OF CALIFORNIA Ae -•• °O: STATE WATER RESOURCES CONTROL BOARD W dam, o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE „ MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY D. ITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FAGILI I Y/bl I t INI-UMMA I IUN & AUUKtbb - (MUD I CC t uivir= I CU) DBA OR FACILITY NAME Qv K TSP I'MArt t� 17-1 NAME OF OPERATOR Q IL '5'T-">rP1�tA�r2 4675 /NC ADDRESS -r NEAREST; o STREET RQ PARCEL (OPI I' t� L G(J( 7- V UUM{ '0► !t CITY NAME STATE ZIP CODE SITE PHONE It WITH AREA CODE MCA, CA S33(� - 9,s1- —7-95-1- ✓ BOX CORPORATION Q INDIVIDUAL a PARTNERSHIP 0 LOCAL -AGENCY Q COUNTY -AGENCY' Q STATE -AGENCY` FEDERAL -AGENCY' V TO INDICATE DISTRICTS ' 8 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. 1. D. # (optional)ESEATION Q 3 FARM 0 4 PROCESSOR Q 5 OTHER ORTRUST L P�ANDS CAL 600 045' '7 ZO EMERGENCY CONTACT PERSON (PRIMARY) " EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FI I 1 11PHONE,,,( PITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE f. M E g �--I'R-v 10 NIGHTS: NAME (LA T, FIRST) ONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) P ONE # WITH AREA CODE 'Sf 1069 � ✓ box to indicate flStINDMIJUAL E] LOCAL -AGENCY II. PROPERTY OWNER INFORMATIQN,-AUST BE COMPLETED) ` �6 NAME _ CARE OF ADDRESS INFORMATION f. M E g �--I'R-v 10 MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL MAILING OR STREET ADDRESS P. ®� yC" a -S ✓ box to indicate flStINDMIJUAL E] LOCAL -AGENCY STATE -AGENCY 4 VAS vE Q CORPORATION 0 PARTNERSHIP Q COUNTY -AGENCY (] FEDERAL -AGENCY CITY NAME 64 STATE ZIP CODE PHONE # WITH AREA CODE /J TOSE I I CA o 3 III_ TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION DATE MONTHIDAYNEAR VV- T'o P fi2I< 04C. M E g �--I'R-v 10 MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL -AGENCY STATE -AGENCY P. ®� yC" a -S 1j;a-CORPORATION 0 PARTNERSHIP 0 COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE e o(` I 64 �-145-3-3- _, ✓ 1 a (P"— J320 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 V,box to indicate (] 1 SELF-INSURED = 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND Q 6 LETTEROFCREDIT = 6 EXEMPTION 7 STATE FUND 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. ❑ it. ❑ III.. THIS FORM HAS BEEN IPMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME ( RINTED SI A E) TANK OWNER'S TITLE DATE MONTHIDAYNEAR mi ,4tW4. 6W r- 10 LOCAL AGENCdNLY " COUNTY # JURISDICTION # FACILITY # LOCATION CODE - OPTIONAL I CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE . OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AST (1) OR MORE PERMIT APPLICATION - FORM B, UNLEWIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA (6-95) i OWNER MUST FILE THIS FO THE LOCAL AGENCY IMPLEMENTING THE UNDERGRRF STORAGE TANK REGULATIONS