COMPLIANCE INFO_1986-1999 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA 7 STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA rs COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT n CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SIT 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 OF OPERATOR ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 225 a o �.(`r1�t� _ t1 �w s1'- 14-1 - 21+ — U3 CITY NAME 1 STATE ZIP CODE SITE PHONE#WITH AREA CODE C-K— CA cl S'ZOS ?zej 46-- 1o-- ✓BOX CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q 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 Q 2 DISTRIBUTOR RESERIF #OF TANKS AT SITE E.P.A. 1.D.#(optional) C;jOv{� Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS �_? 000 � 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 f �� 63RD �� _� iS�c� KPYfZW� `I-IrY111C- 510_ j 0 _ N iT NAME(LAST,FIRST) /U> I T)F3 R-PO / PHONE#WITH AREA CODE NIGHTS:.NA E( FIRST) '� �`POHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) `�V/iVp`� 11M,, `^t'�T cam✓ NAME CARE OF ADDRESS INFORMATION DIU..01-A Com ppvj I,IF---S It�C- _ ke Aft MAILING OR OR STREET ADDRESS ✓ bo o indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY P_o — W I�G CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE o III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION diU\ SVOfi' N �� MAILING OR STREET ADDRESS ✓ Vto indicate Q INDIVIDUAL Q LOCAL-AGENCY =STATE-AGENCY CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATEZIP C DE PHONE#WITH AREA CODE Stf IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F4-F41- -101 6 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate Q 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT Q 6 EXEMPTION Ml 7 STATE FUND Q 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND&CERTIFICATE OF DEPOSIT a 10 LOCAL GOVT.MECHANISM a 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.❑ II.❑ III. THIS FORM HAS BEEN CO ETED D R PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAW(PRINT &SIAT E) TANK OWNER'S TITLE DATE MONT Y/YEAR tin 1 tea-- _ thG R_ 14' �-- LOCAL AGENCY US COUNTY# JURISDICTION# FACILITY It ❑ 10111 f I 11 LOCATION CODE -OPTIONAL 76ENSUS TRACT It -OPTIONAL 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. OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGROTORAGE TANK R;GULATIOX FORM A(6-95) 1 JJ