COMPLIANCE INFO_1986-2002 - Laserfiche WebLink

Home Browse Search

�'OURCCS STATE OF CALIFORNIA APP cO r STATE WATER RESOURCES CONTROL BOARD W dam, v UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE • Cil,-pR H,r MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ONE ITEM ❑ 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FA I ITY NAME CAR OFADDDREESS INFORMATION 1 I, k� _V,V ILJ V MAILING OR STREET ADDRESS NAME OF OPERATOR Q , MAIDOR STREET ADDRESS CITY NAME STATE t/ boxtoindicate 0 INDIVIDUAL O LOCAL -AGENCY (� STATE -AGENCY 1 0 ADDRESS = CORPORATION = PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY NEAREST CROSS STREET PARCEL # (OPTIONAL) STFjTE, ZIP CODE PHONE # WITH AREA CODE UN I oN CITY NAM STATE ZIP CODE SITE PHONE # WITH AREA CODE CA . 2 ✓ BOX Q CORPORATION 0 INDIVIDUAL O PARTNERSHIP Q LOCAL -AGENCY COUNTY -AGENCY' O STATE -AGENCY' Q FEDERAL -AGENCY' TO INDICATE DISTRICTS If owner of UST is a public ageplete 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) 0 3 FARM a 4 PROCESSOR 0 5 OTHER RESERVATION OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DUY:,NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PH E # WITH AREA CODE �cE. I - $ do �a51.ice► I NIGHTS: NAME (LAST, FIRST) PHON # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE If WITH AREA CODE II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAM 4 CAR OFADDDREESS INFORMATION 1 I, k� _V,V ILJ V MAILING OR STREET ADDRESS CARE OF ADDRESS INFORMATION Q , MAIDOR STREET ADDRESS CITY NAME STATE t/ boxtoindicate 0 INDIVIDUAL O LOCAL -AGENCY (� STATE -AGENCY 1 0 5 = CORPORATION = PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STFjTE, ZIP CODE PHONE # WITH AREA CODE III. TANK OWNER INFORMATION -(MUST BE COMPLETED) NA OF OWNER 14 CAR OFADDDREESS INFORMATION 1 I, k� _V,V ILJ V MAILING OR STREET ADDRESS ✓ boxto indicate 0 INDIVIDUAL LOCAL -AGENCY STATE -AGENCY Q , O CORPORATION PARTNERSHIP 0 COUNTY •AGENCY 0 FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. TY (TK) HQ F4]4-] - V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box to indicate 0 1 SELF-INSURED 0 2 GUARANTEE = 3 INSURANCE = 4 SURETY BOND 0 5 LETTER OF CREDIT O 6 EXEMPTION 0 7 STATE FUND 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 1 or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. ❑ II. ❑ 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 OWNER'S TITLE DATE MONTHtDAYNEAR LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # FACILITY If LOCATION CODE - OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT L�T (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA (6-95) OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO9TORAGE TANK REGULATIONS