BILLING 1986-1997 - Laserfiche WebLink

Home Browse Search

�zoa« STATEOFCAUPORWA STATE WATER RESOURCES CONTROL BOARD w„ � _ .b o UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A ? , COMPLETE THIS FORM FOR!ACRfACILITYISITE MARK ONLY O I NEW PERMIT E:] 3 RENEWAL PERMIT Rn 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLO D SITE ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT I] S TEMPORARY SITE CLOSURE QZ I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME /' NAME OF OPERATOR e �eyleor c( 5'ca/ ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) �' (7 �. W Z%a'C'C✓IOD ��X CITY NAME STATEA ZIP CODE SITE PHONE WITH AREA CODE 95 z d5 TO INDI ATE O CORPORATIONDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY Ej CO UNtY.AGENCY' O STATE-AGENCY' ED FEDERAL AGENCY' DISTRICTS,or office N owner of UST Is a public agency, he IollovAng:name of Supervisor of division,section, office whish operates the UST TYPE OF BUSINESS GAS STATXDN Q 2 DISTRIBUTORQ ✓ IF IVATION NDIAN #OF TANKS ATSITE E.P.A. I.D.#Ooprio-W) 3 FARM 0 4 PROCESSOR Q flESER 6 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE f ✓f 'ni tHie y'3/-o'�Flso NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓box blnOkets INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY ED CORPORATION PARTNERSHIP O COUNTY-AGENCY 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 ✓ bob Indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY Q CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 it questions arise. TY(TK) HQ 4 4- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED box tokdkate O I SELF INSURED 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND 1:3 5 LETTEROFCREDIT Q 6 EXEMPTION Q 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I I is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.0 III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNERS NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY It JURISDICTION# FACILITY t Z3 GI LOCATIONCODE -OPTIONAL / CENSUSTRACT# OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL S-z`1-5 y 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 FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(3^Y3) 0 0 ^ FOROUI9A.Ri