COMPLIANCE INFO_1995-2002 - Laserfiche WebLink

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� - ,� � • C6pVR � P �uut• STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD r 4a 1 8 UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A vs COMPLETE THIS FORM FOR EACH FACILITY/SITE It'ror<N', MARK ONLY 0 t NEW PERMIT a 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE REM F-1 2 INTERIM PERMIT E::] 4 AMENDED PERMIT F-1 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FA ILITY NAME ) NAME OF OPERATOR Goy ADORES NEAREST CROSS ST ET PARCEL#(OPTIONAL) f I'7/ t4- dwY FRI ye-6-m-cm CIN IIAME STATE ZIP CODE SITE PHONE#WITH AREA CODE CA �'�'�Z�U TOINDBI ATE 0 CORPORATION =INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' (] STATE-AGENCY FEDERAL-AGENCY' DISTRICTS' If 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%�L27 ' GAS STATION 0 2 DISTRIBUTOR RESERVATION IF INDAN #OF TANKS AT SITE E.P.A. I.D.#(optional) 3 FARM Q 4 PROCESSOR Q 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 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER I FORMATION• MUST BE COMPLETED NAME^._ � CARE OF ADDRESS INFORMATION 110 MAILING OR STREET ADDRESS ✓box 0indicate ENINDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY ®0 5'- �!!Qd!51 D CORPORATION TNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STA ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNERCARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box b indicate IVIDUAL LOCAL-AGENCY STATE-AGENCY Qp r'. CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE F<� 1- i3;2Q, 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 ✓box b Indicate t SELF-INSURED Q 2 GUARANTEE [=1 3 INSURANCE E::]4 SURETY BOND (�5 LETTER OF CREDIT 0 6 EXEMPTION = 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: 1. II. 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# Ck 0311 LOCATION CODE -OPTIONALCENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OP77ONAL D T14S FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATbN- FORM B,UNLESS THIS LS A CHANGE OF SITE INFORMATK)N ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATK= FORM A(3193) 0 0 FOROMM-R7