BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

ov�ccs STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A as , 41 COMPLETE THIS FORM FOR EACH FACILITY/SITE '� ° . MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR TE coF—QLAILpn/ F 7C--f2_P?_ISE5 ADDRESS NEAREST CROSS STREET PARCEL#(0 TIONAL) yyD U1. Char-tCc-f- \/V Lk I(o 5 -030 -o CIN NAME STACE4 ZIP CODE 152-o,5 �� SITE PHONE#WITH AREA CODE 5-ro ckTo>v ✓ BOX CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' TO INDICATE DISTRICTS If owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST TYPE OF BUSINESS % t GAS STATION Q 2 DISTRIBUTOR Q ✓IF INDIAN #OF TANKS T SITE E.P.A. I.D.#(optional) �1 RESERVATION Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: AME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE \)L-AN`p 2E 925-75-7- Ig95 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 40VLA,NT) (ZE.' 915- 76(o-3)'39' If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CCARE OF ADDRESS INFORMATION I�UILO� NTLI~ IZISI:S LLC, 13RL'TI fWLNND MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY T.V, 2)ox .5O SD [CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE A9-T/NEX CA 9((53 X25 75-7, 1195' III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NA E OF OWNER CARE OF ADDRESS INFORMATION Qu1L�N �✓ -TF F K-jSFS LL6- $ T TJ�10 L.IQt.1 MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY ?. 0. o X 9090 CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE n(1ar+Ir��2 CPt cl Lf 53� '725- 75-7- 1115 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 44- -1 01311 d 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 BOND Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 7 STATE FUND Q 8 STATE FUND d CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND&CERTIFICATE OF DEPOSIT Q 10 LOCAL GOVT.MECHANISM Q 99 OTHER 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: I.❑ 11.❑ 111. F RM HAS BEEN OMPLETED UNDER PEN, TY OF PERJURY,AND TO THE BEST OF MY KNOWL GE,IS TRUE AND CORRECT T NK OWN NAME(PRINTF SIGNAT TAN NER'S TITLE TE MONTHID /YEA CAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 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 FC 'ITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGr D STORAGE TANK REGULATIONS FORM A(6.95)