BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATEOFCAUFORMASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM ��4A COMPLETE THIS FORM FOR EACH F CILITYISITIE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 RMANENT ED SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBAOR FACILITY NAME 0j NAME OF OPERATOR ADDRESS r V /�^ NEAREST CROSS STREET PMCEL#(OPFIOWIq iV V �J CITY NAME STATE ZIP CODE .3 / SITE PHONE#WITH AREA CODE Box TOINOCATE O CORPORATION INDIVIDUAL O PARTNERSMP U CAL-AGSENCY _ O COUNTY-AGENCNCY' bO STATE-AGENCY' O FEDEML-AGENCY' N~or a UST Is a pubfic agency,amplele the fulloeAng:name of Supervisor of division,section,or office Which operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR 0 ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#topenMl) RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ bus Isindicate 0INDIVIDUAL LOCAL AGENCY STATE AGENCY D CORPORATION O PARTNERSHIP O COUNTY-AGENCY FEGERAUAGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓6mbYNicaN INDIVIDUAL O LOCAL AGENCY O STATE-AGENCY 0 CORPORATION PARTNERSHIP O COUNTYAGENCY 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 M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED ✓ bov biMkale O 1 SELF-INSURED 2 GUARANTEE ILJ 3 INSU E a SURETY BOND O 5 LETTEROFCREDTr O 6 EXEMPTION HER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. 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'S TITLE DATE MONTWDAY EAR LOCAL AGENCY USE ONLY j COUNTY C JURISDICTION s FACILITY s LOCATIONCODE - TAONAL CENSUZ T}�-,fT^TA7NAL SUPVMM-DISTRICT CODE -OPTIONAL 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS 1S A CHANGE OF SITE LWORMATION ONLY.. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(393) FOR=3A4n