COMPLIANCE INFO_1994-2001 - Laserfiche WebLink

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,ygt7 STATE OF CAUFORNIA STATE WATER RESOURCES CONTROL BOARD 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 0 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR DATE MONTWDAYNEAR e_— ).73 --( 173 ADDRESS CROSS S EET PARCEL N (OPTIONAL) GUT-Le�f,> _&j-,'LAe_g5l 5' D— NEAREST 6d CITY NAME STATE ZIP CODE SITE PHONE # WITH AREA CODE I f�l CA 53G, --,V NorYt�s iu�r �a BOX TOINDICATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL -AGENCY Q COUNTY -AGENCY' Q STATE -AGENCY' Q FEDERAL -AGENCY' 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 Q 2 DISTRIBUTOR Q ✓ IF INDIAN 1# OF TANKS AT SITE E. P. A. 1. D. # (optional) Q 3 FARM Q 4 PROCESSOR Q 5 OTHER RESERVATION OR TRU T (LANDS 7© EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - oottonal DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DATE MONTWDAYNEAR e_— ).73 --( 173 NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE L4—G -1 GUT-Le�f,> _&j-,'LAe_g5l 5' D— II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION DATE MONTWDAYNEAR d ( U ,52. S4- MAILING OR STR ET ADDRESS ✓ box loindicate Q INDIVIDUAL Q LOCAL -AGENCY Ll STATE -AGENCY MAILING OR STREET ADDRESS ✓ box b Indicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY 6d ;254ORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY CITY NAME STATE ZIP CODE J.PHONE # WITH AREA CODE efiE-, It ktb-rel G LT -7 a o - k- Ll rk-H (90 1 i 734 --64D0 III. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION DATE MONTWDAYNEAR d ( U ,52. S4- MAILING OR STR ET ADDRESS ✓ box loindicate Q INDIVIDUAL Q LOCAL -AGENCY Ll STATE -AGENCY Q 5 !!so CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY CITY NAME STATEZIP CODE PHONE # WITH AREA CODE Bte C 4 fdr� G rT �f�©Z J/ r_ 430 z IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. TY (TK) HQ 4 4 - Q 1 aJ I ` V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box toindicate �I 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND 5 LETTER OF CREDIT Q 6 EXEMPTION 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: I. ❑ II. ❑ III T141S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT OWNER'S NAME (PRINTED & SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR '� I. l,.4 _j b >.-I t; . 601-, r--0 I-, Its -7-7 Of --4 Cv�Z3-9�' LOCAL AGENCY USE ONLY COUNTY # JURISDICTION# v� U FACILITY # �P I y m 15V1j;:V1 LOCATION CODE - OPTIONAL I CENSUS TRACT # - OPTIONAL _ w _ 0% A SUPV1SOR - DISTRICT CODE - OPTIONAL I THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B. UNLESS THIS M A CHANGE of sITE wmiumilm nim v OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATK)NS FORM A (3/93) 4t IR N / FOROM3A-R7