BILLING - Laserfiche WebLink

Home Browse Search

SpURCES r STATE OFCALIFORNIA STATE WATER RES URCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A � �D 0 p�(IFpp N� COMPLETE THIS FORM FOR EACH ACILITY/SITE MARK ONLY �I' 1 NEW PERMIT E] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL S SITE ONE ITEM 2 INTERIM PERMIT E::] 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS .. NEAREST CROSS STREET PARCEL#(OPTIONAL) ZU'( S � W� l S�n (,✓ CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE 5,4v ac ✓ BOX TO INDICATE CORPORATIONDIVIDUAL = PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(opfionai) 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS I EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE:#WITH AREA COnF II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME - CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box ID indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY Com' C44c, }/✓ 0 CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE S)-& `-(c /z,-, CA 7 S` Z III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box toindicate INDIVIDUAL 0 LOCAL-AGENCY (] STATE-AGENCY Q CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 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 1 4 4�-A 3 Z Z V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)-IDENTIFY THE METHOD(S) USED ✓ box to indicate 1 SELF-INSURED 2 GUARANTEE =] 3 INSURANCE 4 SURETY BOND 5 LETTER OF CREDIT 6 EXEMPTION E-1 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless*1 or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. IIAV III. THIS FORM,HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONTH/DAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTIO # FACILITY# ? 3 1 13 1 0 LOCATION CODE -OPTIONAL ICENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 01 23 s 3 - r--- - �X�f THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT AP LIGATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION LY. FORM A(12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 0 0 OR 033A-R6