BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 'm UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE �O I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DPA O.VACILITY NAMES NAME OF OPERATOR C r-ai1 T -- ADDRESS I ` / \ / NEAREST CROSS STREET PARCEL+(OPTIONAL) CITY NAS I STAGER ZIP CODE SITE SITE PHONE 8 WITH AREA CODE -/ BOX LOCAL-AGENCY TOINOICATE O CORPORATION O INDIVIDUAL. D PARTNERSHIP O LOCAL-GE 1771COUKrWAGENCY' O STATEAGENCY' O FEDERALAGEWY' DISTRIN owner d UST Is a public agency,complete the following:name or Supervisor of division,section,or office which operates,the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR gESEIF RVNDDION a OF TANKS AT SITE E.P.A. I.D.a(epl/onal) ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box bindicate Q INDIVIDUAL LOCAL AGENCY ] STATE AGENCY D CORPORATION 0 PARTNERSHIP 0 COUNTY AGENCY = FEDERALAGENCY CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box blndkNe Q INDIVIDUAL LOCAL-AGENCY STATE AGENCY O CORPORATION 0 PARTNERSHIP COUNTYAGENCY Q FEDERAL-AGENCY CITY NAME - STATE ZIP CODE PHONE a WITH AREA CODE IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HO 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box bindkale 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE O 4 SURETY BOND O 5 LETTEROFCREDIT ]6 EXEMPTION Q W 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. II.❑ HE❑ 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) OWNERS TITLE DATE MONTHIDAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# a LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -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 FORM A(3(93) FORe033AA7