COMPLIANCE INFO_1986-1995 - Laserfiche WebLink

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�5o�aces STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A d COMPLETE THIS FORM FOR EAC ACILITYISITE MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT s CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE CNE ITEM ❑ 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME STATE ZIP CODE // SITE PHONE#WITH AREA CODE x1J J'? CA ✓ BOX TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR0 RESERVAIF NDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) Q 3 FARM Q 4 PROCESSOR Q 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) 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box_ Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY �i RPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY ---------------- CITY NAME STATE ZIP C PHONE#WITH AREA CODE 111. T OWNER INFORMATION-(MUST BE COMPLETED) NA OF EVERCARE OF ADDRESS INFORMATION e'/ �.v�eC)'C CJ� C'r MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q fEDERAI•AGENCY CITY NAME STATE ZIP CODE PHONE#WITH7EA CODE � v<-d c IV. ARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) 14 4 -Ill p "? V. PETROLEUM UST FIN ANCI — IFY THE METHOD(S) USED ✓box Io indicate Q 1 SELF-INSURED Q 2 GUARANTEE 3 INSURANCE Q 4 SURETY BOND Q 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: 1.= 11.❑ 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 MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# Cl I/-F'/ 1-7 171 LOCATION CODE -OPTIONAL CENSUS TRACT#•OPT70NAL 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. FORM A(5.91) FOR0033A-5 1 •