COMPLIANCE INFO_1987-1995 - Laserfiche WebLink

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'OUR es STATE OF CALIFORNIA c�1 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 4 • c�I IFOR N� COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY IV 1 NEW PERMIT 7 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SIT ONE ITEM [:] 2 INTERIM PERMIT [_1 4 AMENDED PERMIT [:] 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DB R FACILITY NA NAME COF�oh PE �Lem VV A S NE IGT CROSS STREE� PARCEL#(OPTIONAL; CITY NAME /!w STATE ZIP CODE SITE PHONE#WITH AREA CODE CA -- ✓ Box TO INDICATE O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS F__] 1 GAS STATION = 2 DISTRIBUTOR ✓ IF INDIAN #OF TAN S AT SITE E.P.A. I.D.#(optional) RESERVATION 0 3 FARM = 4 PROCESSOR = 5 OTHER OR TRUST LANDS 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 CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY CORPORATION PARTNERSHIP COUNTY-AGENCY 0 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• ✓ box IDindicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY 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 L4L]-[o 0 t� V. PETROLEUM UST FINANCIASPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box to indicate 1 SELF-INSURED [_1 2 GUARANTEE 3 INSURANCE 4 SURETYBOND 5 LETTER OF CREDIT [=]6 EXEMPTION 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.[_—] II.= 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) APPLICANTS TITLE DATE MONTH/DAY/YEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION COD OPTIONAL OONLY.I CENSUS TRACT# -OPTIONAL i SUPVISOR-DIS CTCDE -OPTIONALTHIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNL SS THIS IS A CHANGE OF SITE INFORMA FOAM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 0 FOR0033A-R6