COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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STATE OF CALIFORNIA A� ° STATE WATER RESOURCES CONTROL BOARD W vim, UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY El 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE ONE ITEM [::] 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR CA t-I j aRN T,4 9 n'P ADDRESS Zq r Rc NEAREST CROSS STREET PARCEL N(OPTIONAL) CITY NAME,,t , � �c7 STACEA ZIP CODE SITE PHONE#WITH AREA CODE ✓ BOX Q CORPORATION u INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' IQ STATE-AGENCY' Q FEDERAL-AGENCY' TO INDICATE DISTRICTS 8 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 1 GAS STATION 2 DISTRIBUTORQ VIFINDIAN IIRVATION #OF TANS$$AT SITE E.P.A. I.D.#(optional) VV IQ 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: AME(LAST,FIRST) PHONE#WITH AREA CODE �i4g-n. 2o- .- 116 7_ L12- 7 2 NIGHTS: NA (LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE t'� 7. L-z 2,a9_ y6:7_ YS 72- TJ-4' PAA-,ti 2-69_ y6 7- y2 ZZ II. PROPERTY OWNER INFORMATION-(MUST BE COMPLPTFI)) NAMECARE OF ADDRESS INFORMATION ;VU1 0J / LL dUNfT 7' PllA�1 MAILING OR STREET ADORESg(� ^,/- ✓ bcx U = I' IVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY 2-VS7_3 '7�7�G�7u AV e— IQ CORPORATION PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME B/`Y- 9 S2•J C! STATE ZIP CODE PHONE#WITH AREA CODE 17 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNERp f` , CARE OF ADDRESS INFORMATION u4 N 7-,. LE W>�. (7 llj d'lh'A J MAILINGORSTREET ADDRESS ✓ box to indicate � I DIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY CORPORATION PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAM 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) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓box to indicate Q 1 SELF-INSURED Q 2 GUARANTEE 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT Q 6 EXEMPTION =7 STATE FUND Q 8 STATE FUND d CHIEF FINANCIAL OFFICER LETTER Q 9 STATE RIND&CERTIFICATE OF DEPOSIT Q 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.= it.0 III. 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 MONTHfDAYNEAR LOCAL AGENCY USE ONLY ff COUNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL O I � 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 UNDERGROOTORAGE TANK REGULATIONS FORMA(6-95)