COMPLIANCE INFO_1997-2007 - Laserfiche WebLink

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a , - STATE OF CALIFORNIA :r °a STATE WATER RESOURCES CONTROL BOARD W dam, e UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY P!rl NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED,SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR :TAf5 m 1 N I MAP KET 7'A A c I L Ra4 ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 0� WEST LANE ALP n/E 1 -- 0 -- 31 CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE 5TocYToN CA C1,"2.0( 2-09— 4(0- I 65 Ze ✓BOX CORPORATION INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' Q STATE-AGENCY' 0 FEDERAL-AGENCY' TO INDICATE DISTRICTS 9 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 ❑ 2 DISTRIBUTOR ❑ ✓IF INDIAN I#OFTANKS AT SITE E.P.A. I.D.#(optional) ESE Q 3 FARM 0 4 PROCESSOR Q 5 OTHER ORTRUSTVATION LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AF(EA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE I LRA Z_fl 7_09- 2-8l0l NIGHTS: NAME(LAST,FIRST) PHONE If W(,TH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Nc i LRA-t' SA y z -r' 7 -- 7118 II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME � m C i LRR?-M CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL I]LOCAL-AGENCY (] STATE-AGENCY 19 0_45 616 J D?,,I VE 0 CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 5_rb WTC>A) Get `3SZD 6 S40q (oZ--8'Z0_' III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION 5 O-1 IL.R 6TH MAILING OR SThEEt ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY 14105I.v1 (]CORPORATION Q PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP COo E PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 44- -101 Z I 4 1(ra 12 171 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 1 SELF-INSURED =2 GUARANTEE =3 INSURANCE Q 4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION 1=1 7 STATE FUND O 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER O 9 STATE FUND&CERTIFICATE OF DEPOSIT O 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: 1.❑ II. '" III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT E TANK OWNER'S NAME(PR TED& ATURE) TANK OWNER'S TITLE DATE MONTH/DAYNEAR TANK; L AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY 1/7 Lu � .9 LOCATION CODE —OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE •OPTIONAL h C i ,(t 2 7 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 FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGROGIST ORAGE TANK REGULATIONS FORM A(6-95)