COMPLIANCE INFO_1986-1997 - Laserfiche WebLink

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•r 0• `so�nces STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD W dam, UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE • CSI IR°R N'� MARK ONLY D 1 NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY OSE . SITE ONE ITEM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME • ✓ , J i DAYS: NAME (LA T, FIRST) P ONE # WITH AREA CODE NAMk OF OPERATOR ADDRESSNEAREST I CROSS STREET PARCEL # (OPTIONAL) O - 0;1' min 0 CORPORATION PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY CI AME M CITY E CITY NAME ZIPCODE �y -7f7 /��{Q PHONE # WITH AREA CODE STATE ZIP CODE SITE PHONE # WITH AREA CODE 0670 Aj CA ✓ BOX CORPORATION D INDIVIDUAL CD PARTNERSHIP LOCAL -AGENCY a COUNTY -AGENCY' STATE -AGENCY' Q FEDERAL -AGENCY' TO INDICATE DISTRICTS ' N owner of UST is a public agency, complete the following-. name of supervisor of division, sedan or office which operates the UST TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN J#OFTANKS AT SITE E.P.A. I. D. # (optional) 0 3 FARM Q 4 PROCESSOR Q 5 OTHER RESERVATION OR TRUST LANDS FMF:Qr-FNCY cnNTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - ootional D YS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LA T, FIRST) P ONE # WITH AREA CODE . -- C:U' I NI HTS: NAM (LAST, FIRST), PHONE # WITH AREA CODE NIGHTS: NAME (LA T, FIRST) PHONE # WITH AREA CODE O - 0;1' min II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NA nn T CARE OF ADDRESS INFORMATION -- C:U' I MAILING OR STREET ADDRESS I ✓ box to indicate INDIVIDUAL LOCAL -AGENCY STATE -AGENCY L� LOCAL -AGENCY STATE -AGENCY n ^ r G� a:►v 0 CORPORATION PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY CI AME M CITY E STA-LF,4 ZIPCODE �y -7f7 /��{Q PHONE # WITH AREA CODE III TANK nWNFR INFORMATION .(MUST BE COMPLETED) NAME OF OWNER CAPr. F ADDRESS INFORMATION ,eY) MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL L� LOCAL -AGENCY STATE -AGENCY D)CORPORATION PARTNERSHIP COUNTY -AGENCY QFEDERAL-AGENCY M CITY E STATE ZIP CODE PHONE # WITH AREA CODE a..ccjj;;A, O N/ IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. TY (TK) HQ4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY -(MUST BE COMPLETED) -IDENTIFY THE METHOD(S) USED ✓ box to indicate YV i SELF-INSURED O 2 GUARANTEE = 3 INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION = 7 STATE FUND a 8 STATE FUND d CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND 8 CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT. MECHANISM O 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. a III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT I'ANK OWNER'S NAME (PRINTED & SIGNATURE) NK OWNER'S TITLEDATE MONTHfDAY/YEAR �9RA ♦ S - LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # FACILITY # �), e LOCATION CODE - OPTIONAL CENSUS TRACT # -OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL THIS FORM MUST BE ACCOMPANIED BY ATMT (1) OR MORE PERMIT APPLICATION - FORM B, UNLES IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGRONWTORAGE TANK REGULATIONS FORM A (6-95)