BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :s - COMPLETE THIS FORM FOR EACH FACILITY/SITE m MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ # AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE S� ! I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY A AME OF OPERATOR ADDRESS /' NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME �., /7-- STATE ZIP CODyS/��..y. S EPHONE WITH AREAOD�O CA YS //ten ]r J ✓ BOX O CORPORATION (] INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' = FEDERAL-AGENCY' TO INDICATE DISTRICTS I merol USTk a pobk agua y.cwopMto MB(olbwing:�M supervisor M tlivisb .sedion oroffce which operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR = ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION 0 3 FARM O # PROCESSOR 0 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 II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OU�ET A6DRZ, ✓ box to *Me Q INDIVIDUAL OCAL-AGENCY STATE-AGENCY J1 ED CORPORATION O PARTNERSHIP D COUNTY-AGENCY FEDERAL-AGENCY I CITU NAME S,j1TE. ZIP CODES _�,& PHONE#WITH AREA CODE #/yS III. TANK OWNER IN MATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET AD DRE ♦ ✓ boa to ntlimb INDIVIDUAL LOCAL-AGENCY STATE-AGENCY ' / O CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITY NAMESTATE w ZIP CO PHONE#WITH AREA CODE IV. BOARD OF EQUAI IZAWIONEQUALUST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F4-[4--]- V. 4 -� V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ wto lMkale 0 1 SELF-INSURED O 2 GUARANTEE D 3INSURANCE O A SURETYBOND 0 5 LETTEROFCREDIT 0 6 EXEMPTION ]STATE FUND O8 STATE NIA&CHIEF FINANCIAL OFFICER LETTER 09 STATE FUND&CERTIFICATE OF DEPOSIT 010 LOCAL GOVT.MECHANISM I= WOTHEfl 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: 1.❑ II.❑ 111.O THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# m ff�yl ALJ 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 INFORMATION ONLY. OWNER MUST FILE THIS FOP TH TH' 'AL AGENCY IMPLEMENTING THE UNDERGRr STOP TANK REGULATIONS FORM A(&95) ` `✓ v