COMPLIANCE INFO_1995-2002 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD W dam, UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE 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 C%ovkrA J/ r, T �y cr�'tc/v ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) i 9.11 n Rt'v� SF - M13N A) CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE GOd/ C s"�2D CA � .2 c ✓BOX CORPORATION [_1 INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' = STATE-AGENCY' O FEDERAL-AGENCY' TO INDICATE DISTRICTS #owner of UST is a putic 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 Ift OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION 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) PHONE#WITH AREA CODE dv/w/ij /c„J 2.11 9 3/-i76ti NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 1-y-n 53327& II. PROPERTY OWNER INFORMATION-(MUST BE COMPLF71)) NAME CARE OF ADDRESS INFORMATION 6AIt L, vnC>ij MAILING OR STREET AD/D/RESSQ ✓ bcx tc r ca: (] INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY 497/ Nw !/ CORPORATION Q PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME 9TATE ZIP CODE PHONE#WITH AREA CODE C,a C�1 �SlyD of -3W-S30 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION i3 /2 Gil✓ MAILING OR STREET ADDRESS ✓ boxio indicate 0 INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY /yp'71 111 CORPORATION (] PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY CITY NAME ST TE ZIP CODE PHONE#WITH AREA CODE C n9i Asa ,0 .� yo-.09P IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPON [BILI Y -(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 0 1 SELF-INSURED =2 GUARANTEE 3 INSURANCE =4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION =7 STATE FUND B STATE FUND 6 CHIEF FINANCIAL OFFICER R =9 STATE FUND d CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM ED 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.❑ 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 S SIGNATURE) TANK OWNER'S TITLE DATE MONTHiDAYNEAR GAA'l 8U/1 61AI wNWt LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACT# -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 FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(6-95)