COMPLIANCE INFO_1996-2002 - Laserfiche WebLink

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r STATE OF CALIFORNIA :p . STATE WATER RESOURCES CONTROL BOARD W dam, o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM Ao COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED 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 OPERATOR ADDRESS t g NEAREST CROSS STREET PARCEL#(OPTIONAL) IV/lJ'/ , CITY NAME / STATEji�elF�� SIS��ONE#WITH AREA CODE CA GJ, `/oKJ'1 ✓BOX CORPORATION INDIVIDUAL = PARTNERSHIP Q LOCAL-AGENCY D COUNTY-AGENCY' (]STATE-AGENCYFEDERAL-AGENCY' TO INDICATE DISTRICTS If owner of UST is a public agency,complete the following:name of supervisor of division,sedan or office which operates the UST TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION 0 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST)-pirupolS PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE E (�o NIGHTS: NAME(LAST,FIRST) PHONE#WITH AR CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE it I II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY =CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE INFORMATION- MUST BE COMPLETED III. TANK OWNER ( ) NAME OF OWNER CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ boxtolodicate 0 INDIVIDUAL Q LOCAL-AGENCY (] STATE-AGENCY =CORPORATION O PARTNERSHIP E::] COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME [STATE ZIP CODE PHONE If WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 1 SELF-INSURED JR 2 GUARANTEE =3 INSURANCE ED 4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION O 7 STATE FUND 31, STATE FUND&C FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 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. It.❑ 111.0 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY PR= 1 '76 COUNTY# JURISDICTION# FACILITY# .0 a�� LOCATION CODE-OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL , p N2 II z1 97 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 FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO STORAGE TANK REGULATIONS FORMA(6-95)