BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

rI ° STATE OF CALIFORNIA p ,, STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE "Z I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA ORT,ACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#16F NAL) 3cx- Ac 4c �5 CITY NAME lo� STATE ZIP CODE b 6 SITE PHONE#WITH AREA CODE CA ✓ BOX TOINDICATE ED CORPORATION Q INDIVIDUAL 0 PARTNERSHIP [-D LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY (] FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR / ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I. #(apfimalJ L^ Q/ / Q 3 FARM O 4 PROCESSOR RESERVATION 5 OTHER OR D.TRUSTLANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) HONE#WITH AREA CODEDAYS: NAME(LAST,FIRST) doe. Z S - Z131 NIGHTS: NAME(LAST,FI T) ONE# ITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CC II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME ; tl �( (� e SC�©U� S` - CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS/ 1.ITC/1) '\I ✓bwbiMlwe 0 INDIVIDUAL � LOCAL-AGENCY O STATE-AGE14CY /V. /y'C 4 C t`� CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY [:] FIEDEMLAGENCY CITU NAME \ O ^ STATq ZIP �-3& 6 PHONE#�jWITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CC NAMEOFOWNER �— CAREOFADDRESS INFORMATION MAILING ORSTREETADDRESS ✓ boa biWicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY =CORPORATION PARTNERSHIP 0 COUNTY-AGENCY Q FEDEHALAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV,BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. TY(TK) HQ 4 4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ hoc ulMitme O 1 SELF-INSURED 2 GUARANTEE O D INSURANCE (]4 SURETY 80N0 O 5 LETTEROFCREDIT 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: I.❑ II. III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION # FACILITY ��eD/U30 3 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 INFORMATIbN ONLY. FORM A(5-91) G//�� OWA-S saw �,,/