BILLING 1987 - 1999 - Laserfiche WebLink

Home Browse Search

eboun es STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD `.';', �)4!T HEALTH a , UNDERGROUND STORAGE TANK PERMIT APPLICATION'=•FOAM A w COMPLETE THIS FORM FOR EACH FACILITrltiALIG 2? `1 3 8 `. MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY 6 - ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1 I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR AQCp�tAc��k stkly I Ulf I G'AT ENTeQ �Se4 ADDRESS .-` NEARE��j CROSS STREET PA CEL#(OPTIONAL) %%(3 � • WN SUN WA �l) S NN6TON CITY NAME � STACT/EA ZIP COD �0S SITE�20h E yWITH AREA S'C CVk ro o ((11,, ,O ✓ BOX TO INDICATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q DISTRICTS AGENCY QCOUNTY-AGENCY Q STATE-AGENCYQFEDERAL-AGENCY OtSTRICTS TYPE OF BUSINESS .p INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) W Q RESERVATION F-7, 3 FARM n A PROCESSOR Q 5 OTHER OR T9UST LANDS 3 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY))•optional DAYS: NAME(LAST,FIRST) PHONE#WI H AREA CODE DAYS: NAM (LAST,FIRST) 33 A6\0_ ,b33 �aT LAwReNce. E, Opp NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIR T) /Ahs n 2�/_ Q ltwsw�'& RON 2t�11y - 33 Acro 'IncaNr�'ter Tamen c$vV II. PROPERTY OWNER INFORMATION UST BEJCO 0 - NAME CARE OF ADDRESS INFORMATION huo co�uc�ct Co E�1,% S MAILING OR STREET ADDRESS ✓ box toindicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY •CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATEAREA ZI aor) _loan PHOLJE H�^00<40 �RTes C0► III. TANK 114FIORMATION•(MUST BE COMPLETED) NAME OF OWNS CARE OF ADDRESS INFORMATION �R� Rro&uo ; CO . Irw It S MAILING OR ST ET ADDRESS ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY >e-CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME �D STATE ZIP CODEDE Re)^02'�1� PHONE`#SNIT��OCO��O� `1V.- ARD OF EQUALIZATION UST STORAGE-FEE-ACC-0UNT-t#fM fi)3g/3.9555-4*estions ariise. \l J TY(TK) HQ 4 4 - O ob S Q b V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ box to indicate 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BONG 5 LETTER OF CREDIT Q 6 EXEMPTION Q 93 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is ch CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ III• THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORREC APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE M NTH/ AY/YEAR LOCAL AGENCY USE ONLY R D O COUNTY# JURISDICTION# FACILITY# loO LOCATION CODE -OPTIONAL ICENSUSTRACT -OPTIONAL I SUPVISOR-DISTRICT CODE -OP^TIONA THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(5-91) ��` �, FOR0033A•5 -en; 50.E �aaqu�r Co . b aef fct��.1�e��c�.��v . 1 q?, 4.0 . box 'LOA / 1