BILLING - Laserfiche WebLink

Home Browse Search

• STATE OF CALIFORMA d STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A ,> COMPLETE THIS FORM FOREACHFACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT IJ9 5 CHANGE OF INFORMATION ❑ 7 PERM OSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT I❑— 6 TEMPORARY SITE CLOSURE I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ( o DBAORFALJLITY E' /. D NAME OF OPERATOR ADDRESSNEAREST CROSS STREET PARCELN(OPTIONAO Z CITU NAME STATEZIP15202 SITE PHONE#WITH AREA CODE CA T / BOXINDICATE CORPORATION INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY' O STATEAGENCY' O FEDEMLAGENCY' DISTRICTS' 'It owner of UST Is a public agency,moplete the following:name of Supervisor of division.section,or office which operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR / = RE.1 IF INDIAN SERVATION A OF TANKS AT SITE E.P.A. I.D.A(cptionag ❑ 3 FARM ❑ # PROCESSOR ar 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PONE#WITH 5 A C90F�^ DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE ly'`T NIGHTS: NAME(LAST,FIRS1) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION NIOS MAILING OR STREET ADDRESS ✓ indicate l� INDIVIDUAL 0 LOCALAGENCY STATE AGENCY /L S' i o S� CORPORATION O PARTNERSHIP O COUNTY AGENCY O FEDERALAGENCY CITY NAME�-7rm ST* ZIP C�10� -2- PHONE#WITH AREA CODE I� L//AJC III. TANK OWNER INFORMATION•(MUST BE COMPLETED) NAME OF OWNER 5 ft CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boa In indicate = INDIVIDUAL LOCAL AGENCY 0 STATE AGENCY Q CORPORATION E-:1 PARTNERSHIP 0 COUNTY AGENCY O FEDERALAGENCY 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 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box biMkate = 1 SELF INSURED 2 GUARANTEE 0 3INSURANCE L_j a SURETY BOND 5 LETTFROFCREDT 0 6 EXEMPTION O N OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is ch d. CHECKONE 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 OWNER'S NAME(PRINTED&SIGNED) OWNER'STITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# Lei--�-I-� LOCATION CODE -OPTIONAL CENSUS TRACT OPTIONAL SUPVISOR-DDIISTRICT CODE -OPTIONAL 01 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESSTHIS IS A CHANGE OF SITE micAmAbON ONLY. FORMA(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIM • �/tFORW17A{i7 � PI� fl '