BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

41111110 ! STATE OF CIWPoRNIA y0V••�' ••'•• ° STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE O.4r M' A MARK ONLY O 1 NEW PERMIT L3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ONE REM 2 INTERIM PERMIT Q � T PERMANENTLY CLOSE Q 4 AMENDED PERMIT 5 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA OR FACILITY NAME Q - I A r9iT NAME OF M-L I� D, ADDRESS 1 'T%f-. �✓-�4l I{rIL 33 E.• M/�It l �'T W?1- G { NEAREST CROSS STREE! PARCELi(OPrx)NAu CITY NAME MAIN l INCL I HI6I-IWaY `�� 2rol, �rno , 41 R1 Po N STATE ZIP CODE SITE PHONE i WITH AREA CODE .1 BOX CA 953Cory 20 . 5`l9 2313 TO INDICATE .r�. CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY H ownerd USTIsa ublicl B. DISTRICTS' O COUNTY AGENCY' Q SrATE.AGENCY• O FFIDEML#GEW P +panty,S STATION the tollowin name RI SUPI d tlNMbn,section,w Once whbh operates the UST ED TYPE OF BUSINESS y� t GAS STATION Q 2 DISTRIBUTOR 3 FARM 4 PROCESSOR R SERVATDIAN ION i OF TANKS AT SITE E.P.A. I.O.i(oPtksrel) Q SOTHER OR TRUSTLANDS �}• C.Ql. ocz�2.9ro'-75 EMERGENCY CONTACT PERSON (PRIMARY) DAYS' NAME(LAST EMERGENCY CONTACT PERSON (SECONDARY) FIRST) PHONE a WITH AREA CODE DAYS: NAVE(LAST,FIRST) -apttonel S L 2� 199 . 2?jI CH �� I HOQNE,�Li WITH AgEA CODE NIGHTS: NSE(LAST,FIRST) PHONE A WITH AREA CODE 510 S•,•Z '9'(�r-.,(� NIGHTS: NAME(LAST,FIRST) I---- 'LO�j' 62-60 • 8l 8) C+r'I t�,/pµ1 2^ ��S �� QPHONEi WITH AREA CODE II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED l5/- NAME1 L�� W `P R(d� IICA �D�G� C-oMp CARE OFADDRESS INFORMATION L,,I Ajy MA IL ING OR STREET ADDRESS V`�? O' Pp r:,..� ✓ EW bhbbAN Q INDIVIDUAL 1!1 LOCAL STATE-AGENCY CITY NAME vvv� Jl-CJ CORPORATION Q PARTNERSHIP E3 COUNTY-AGENCY ED FEDERAL-AGENCY RA M o N STATE ZIP CODE PHONE i WITH AREA CODE cls 945$3 570. 842 `�tX�2 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS C PERMIT DESK ATTN KATHY NORRIS ✓ hot bintlbye ED INDIVIDUAL Q LCOAL-AGENDY ORPORATION 0 PARTNERSHIP O STATE- AGENCY C M �COUNTY-AGENCY (] FEDEMLAGENCY S AMON STATE ZIP cc I PHONE i 1WITH AREA CODE A 9453 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER CCall(916)322-9669 it questions arise50-842-9002 TY(TK) HQ 4 4- - 0 3 1 9 1 3 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓Oot binEkaN �1 SELF-INSURED 2 GUARANTEE 5 LETTER OF CREDIT O B EXEMPTION 0 3 INSURANCE O A SURETY BOND VI. LEGAL NOTIFICATION AND BILLING ADDRESS (] 9B OTHER 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: I. II. III. ApRLI THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT eWNERS NAME(PRINTED 8 SIGNED) 19 III OWNER'S TITLE DATE ONTWDAY/VEAfl LOCAL AGENCY USE ONLY l Y 7 �5 COLINTY i JURISDICTION If I'Sa FACILITY s � LOCATION -OPTX)NALCENSUS TRACT -1W770ANL 6 SUPVISOR-DISTRICT CODE T73 HIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(353) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS y�'�� FOR0033A-R7