BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

x. eyyOUe STATE OF CALIFORNIA o`; STATE WATER RESOURCES CONTROL BOARD W d� UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A - COMPLETE THIS FORM FOR EACH FACILITYISITE °ecooee" o MARK ONLY F--j t NEW PERMIT O 3 RENEWAL PERMIT EZftHANGE OF INFORMATION O 7 PERMANENTLY CLOSE ONE REM F-12 INTERIM PERMIT 4 AMENDED PERMIT E::] 8 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) nRA OR TY NAM 7f � NAME OF OPERATOR ADDRESS �l NEAREST CROSS STREET PARCELO(OPTIDNA() 1 V 07cL6get I CITY STATE ZIP CODE SITE PHONE s WITH AREA CODE TO INDICATE ED CORPORATION D INDIVIDUAL =PARTNERSHIP D LOCAL-AGENCY O COUNTYAGENCY' O STATE-AGENCY' O FEDERALAGENCY' DISTRICTS' •N wmw ot UST Is a pudic age 'co the followbg:name of Supervisor of division,""lion,or office which oPerelff the UST TYPE OF BUSINESS t GAS STATION 0 2 DISTRIBUTOR 0 ✓ IF INDIAN I#OF TAgKS AT SITE E.P.A. I.D.a(opfi ) 0 3 FARM Q 4 PROCESSOR 0 5 OTHEROR ESERVATION TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODEDAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAS ,FIRST) PHONE*WITH AREA DE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE ll. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓Boa blydbats I] INDIVIDUAL O LOCAL-AGENCY O STATE AGENCY D CORPORATION O PARTNERSHIP O COUNTVAGENCY = FEDEMLAGENCY CITY NAME 9TATE ZIP LADE PHONE a WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET-ADDRESS ✓ baabbtlbab Q INDIVIDUAL O LOCAL AGENCY D STATE AGENCY O CORPORATION PARTNERSHIP E�j COUNTY AGENCY D FEDERALAGENCY CITY NAME STATE 2P CODE PHONE A WITH AREA COOS 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 METHODS) USED ✓ Eor bintlbaN 1 SELF INSURED O 2 GUARANTEE 7 URANCE A SU BOND a 5 LETTEHOFCREDIT O 6 EXEMPTION Ga OT ER 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.[j] IL O III.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• I` ® FTJ-311 10 1&Wtti LOCATION CODE -OPTADA14L CENSUS TRACT -OPT)ON4L 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 SrTE m TIONNLY- OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIM FORMA(393) Fdi0037MN7