COMPLIANCE INFO_1992-2000 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A s ._ COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 7 PERMANEN ED 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 CNEVRonJ Sr,1T/o N * 2017 J 4f1-)C-/)Z0)V S T,47Jon/S Me-- ADDRESS GADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 1103 S. M4),V :5 7. M)_SS)o Al CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE M4N7Ee-A CA 9533 6, 009- 89S-0/711 ✓BOX (CORPORATION INDIVIDUAL 0 PARTNERSHIP Q LOCAL-AGENCY 17-1 COUNTY-AGENCY' O STATE-AGENCYFEDERAL-AGENCY' To INDICATE DISTRICTS If 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 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION 0 3 FARM Q 4 PROCESSOR = 5 OTHER OR TRUST LANDS 3 e,4 L Ooo 1) 7 J 9 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE e4S7-JL1_0X)m 909- 8 ZS- v) 7 Ch16W6.A1 M,4) 9_A1 LC NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 5.4M-F_ 209- 521 L'h/E1/,l'0)J EI+9 6EiJc lNl�o. &�-Z31-4623 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION CNE VZOA) 120,o1JGTS G'O. MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL F7 LOCAL-AGENCY Q STATE-AGENCY CORPORATION 0 PARTNERSHIP =COUNTY-AGENCY D FEDERAL-AGENCY CITY NAME STATEZIP CODE PHONE#WITH AREA CODE SA.1 R,4A JO cA S8 -S y 2- 9Soo III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER AO CARE OFADDRESS INFORMATION r 4./CS S-Y GtJEV�P.o ��DlJGrS L_ MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY P, 0, � CORPORATION Q PARTNERSHIP D COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE IF CODE PHONE#WITH AREA CODE s c S�s83 - 4)Z- 90©2 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions ariseL/gZS, TY(TK) HQ 4 4- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 1 SELF-INSURED =)2 GUARANTEE =3 INSURANCE 0 4 SURETY BOND =5 LETTER OF CREDIT 0 6 EXEMPTION =7 STATE FUND D 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND A 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.❑ 11.❑ III.X THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TUE E NAME(P IN /DJC/&SIGNATURE TANK OWNER'S TITLE(/////�/� DATE MONTHIDDAYNEAR �!/V �//C •/ 1 O8 '107 LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# �I LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY ATL T(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(6.95) OWNER MUST FILE THIS FORMI THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO TORAGE TANK REGULATIONS