COMPLIANCE INFO_1992-2005 - Laserfiche WebLink

Home Browse Search

I Ir 0 STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE rtb�u- Cs C Ar �e „ --V o' • C,L �fORH�� MARK ONLY t NEW PERMIT 0 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ONE ITEM CJ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME -1 NAME OF OPERATOR MAILING OR STREET ADDRESS C`'Aw 1r CITY NAME STATE ZIP CODE ADDS • N ST CRO STREET PARCEL#(OPTIONAL) i CITY NAME. -,.S ATE ZIP SITE PHONE # WITH AREA CODE CA '/ Box TO INDICATE O CORPORATION INDIVIDUAL Q PARTNERSHIP LOCAL -AGENCY / Q LOUNiY•AGENCY' STATE -AGENCY' �RAL•AGENCY' DISTRICTS' / ' (t ��,;�•( /i If owner UST is d a public agency, complete the following: name of Supervisor of division, section, or office which operates the UST TYPE OF BUSINESS = t GAS STATION 2 DISTRIBUTOR = 1# OF TANKS AT SITE E. . A. I. D. # (op AmW) RESERVATIONINDIAN 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS f EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME LAST, FIRST) PHONE # WITH AREA COD DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) �PHON WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE II- PROPERTY OWNER INFORMATION - (MUST RF COMPLFTFDI NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL Q LOCAL -AGENCY 0 STATE -AGENCY F-1 CORPORATION PARTNERSHIP l COUNTY•AGENCY = FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE III. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box Inindicate INDIVIDUAL LOCAL -AGENCY STATE -AGENCY CORPORATION Q PARTNERSHIP ['COUNTY -AGENCY 0 FEDERAL -AGENCY CITY NAME STATE ZIP CODE fdHONE # WITH AREA CODE 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 io Indicate 1� 1 SELF-INSURED 2 GUARANTEE = 3 INSURANCE 0 4 SURETY BOND 5 LETTER OF CREDIT D 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: LE' II. a AIL O 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 MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # FACILITY # F71 T7� t. -I LOCATION CODE -OPTIONAL CENSUS TRACT # OPTIONAL SUPVISOR- DISTRICT 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 FORMA (3193) 117 ,i 1