COMPLIANCE INFO_1985-1996 - Laserfiche WebLink

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I' STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 4.��r ,g UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY O 1 NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F__] 7 PERMANENTLY ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE f 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACt7 NAMENAME O OPERATOR ADDRESS NEAREST CROSS STREET PAPCEL#(OPTIONAL) 00 ITY NAME STAfA 21P CODE CSITE PHONE#WITH AREA CODE ✓ lex ORPORATION INDIVIDUAL Q PARTNERSHIP 0 LOCAL-AGENCY TO INDICATE CDISTRICTS' COUNTY-AGENCYSTATE-AGENCY' =FEDERAL-AGENCY' It 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 Est GAS STATION 0 2 DISTRIBUTOR O ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAY NA E(LAST,FI ST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Z04 z 74 NIGHTS: NAME(LAST,FkSlf PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAM ., a ARE OF ADDRESS INFORMATION Vt.C7[.:�-► - � � MAILIW OR STREET ADDRESS ✓bo lndlcate = INDIVIDUAL LOCAL-AGENCY STATE-AGENCY JO 'z/.j 0 liecORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 46reOL I qz,6zz Z3 0 'U3 - 91 I III. TANK OWNER INFORMATION• MUST BE COMPLETED) NAME OF OW l,_ CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box 10 indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY CORPORATION (] PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HOF4 4- - ® D 6 0 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ box bindicate (] 1 SELF-INSURED Q 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND [�5 LETTER OF CREDIT Q 6 EXEMPTION 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.❑ if. III.0 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# !_1� ✓\"1. LOCATION CODE -OPTIONAL CENSUS TRACT-OPTIOA4 SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE hCCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION. FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(M) 0 0 FOR0M3A-R7