BILLING 1985-1999 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD ' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W ss s COMPLETE THIS FORM FOR EA FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMAN CLOSED TE ONE ITEM ❑I 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE101 1 I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR w1 Prf-7 F S T &(( ),j ADDRESS 17'!�'Y Y m' '/ /-<D NEAREST CROSS STREET PTCNAU CITY NAME 4 STATE CA ZIP E SITE PHONE 4WITH AREA CODE I/ Box s3 �G TO INDCATE CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY -I DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION A OF TANKS AT SITE E.P.A. I.D.#(Ophma)) Q 3 FARM O 4 PROCESSOR Q 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) S� PHnNP m WITH AREA NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) 6 Il. PROPERTY OWNER INFORMATION- MUST BE COMPLETED UI NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS baN W#L# O INDIVIDUAL O LOCAL-AGENCY I] STATE-AGENCY I�CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY 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 ✓ WX 0IN"* INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY CORPORATION O PARTNERSHIP Q COUNTY AGENCY O FEDERAL-AGENCY 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 F4-F41-1612-1 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ 5oa biMkala I SELF-INSURED []2 GUARANTEE O 3 INSURANCE O A SURETY BONO 1�5 LETTEROFCRELVT 6 EXEMPTION O 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notilication 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.❑ IL❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY CF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANPS TITLE DATE MONTWOAYIYEAR LOCAL AGENCY USE ONLY f.0 COUNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL (CENSUS TRACT# -OPTIONA SUPVISOR- (STRICT CODE -OPTIONAL THIS 0 M MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,U F SRE INFORMATION ONLY. FORM A(5-91) FORW33A 5 � I