BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

• 0 eOJn [ STATE OFCAUFORNIA • c5i 0 STATE WATER RESOURCES CONTROL BOARD W w�� a UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A :e ,c COMPLETE THIS FORM FOR EACH FACILITY/SITE °��[en�" MARK ONLY O t NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOIED-SIZE ONE REM O 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ORA OR FACILITY NAME NAM FOPERATOR''// ^ ADDRESS N REST CROSS STREET ARCEL#(oPTpNAU I CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE C S G CA ` BOX TO INDICATE D CORPORATION INDIVIDUAL PARTNERSHIPLOCAL-AGENCYTNEASHIP DISTRICTS' COUNTY AGENCYE-3 STATE-AGENCY FEDERAL AGENCY' It owner W UST is a public agent mrrplele the following:name of Supervisor of divisim sectbn,or office which operates the UST TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.#fcpflanal) RESERVATION 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS 3 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional GAYS: NAME(LAST,FIRST) PHONE Y WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 171- NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILIN OR STREETADDRESS ✓ box biMbale I1 INDIVIDUAL LOCALAGENCY STATE AGENCY -+" 0 CORPORATION O PARTNERSHIP COUNTY AGENCY 0 FEDERAL AGENCY GTY NAME STATE ZIP C DE PHONE#WITH AREA CODE CA 3a o III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boz bimicale D INDIVIDUAL LOCAL AGENCY O STATE AGENCY CORPORATION O PARTNERSHIP 0 COUNTY AGENCY 0 FEDERAL AGENCY 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 METHODS) USED ✓ boz b Wicale O t SELF-INSURED 2 GUARANTEE Q 3 INSURANCE O A SURETY BOND 1E] 5 LETrEROFCREDIT D 6 EXEMPTION IN 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, 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 MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTIONAL FACILITY# ® F3T2__F�o 31 11AIA16 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 INFOflMA 0 Y. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATWNS FORM A(393) 0 0 FOROOJ3AA7