BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL FORM 'A': UNDERGROUND STORAGE TANK PROGRAMo 0 SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION " r` 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 ❑ Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5((] 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION vk�i_� j=:N of t N E_ ADDRESS NEAREST CROSS STREET I ✓BmtWuk ❑ PARTNERSHIP ❑ STATEAGENGY /O VD UN/D� �t ❑ DMDDUAL ❑ COUNTY AGENCY RATION C3 LOCAL AGENCY 13 FEDERAL CITY NAME STATE ZIP CODE SITE PHON"E�.WI H AREA CODE ST'oe-14--ry -1 CA `1520 2 X209) ; 6 _ leo TYPE OF BUSINESS' ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓FESBox ii INDIAN EPA ID N N of TANK'N ❑ 1 GAS STATION ❑3 FARM 5 OTHER TRUSTYUINDS or ❑ AT THIS SITE U EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE ko(SsEe .w4p:-rtn4 7""') 464- gSV'L NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION /PaG,ePL 1-f 49-7-W MAILING or STREET ADDRESS �A� q� ✓Box to intlicaDe ❑ PARTNERSHIP - ❑ STATE-AGENCY /D3z. cv' ^ K t4 V/�-„ cv ❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY T , ' /�' ❑ INDIVICORPORAL ❑ LO AL-AG COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE 5-r ec -T- � 157o (Zva% �(6>-�' So III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION - ,,Qp6�e_ .tet*-vjtt MAILING or STREET ADDRESS I ^ -/B ox to nftale ❑ PARTNERSHIP ❑ STATE-AGENCY /v3Zi 0.4X t-Fu IZ9 C( i ❑ INDIVDUAL ON Cl COUNTY-AGENCY 0 LOCAL-AGENCY ❑ FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE X.WITH AREA CODE S vv�6� To tA( � � N6 1.1 - t{ 80 2- IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ it. III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY M FACILITY ID N N of TANKS At SITE O 1 C) Z I I �I 1 O CURRENT LOCAL AGENCY FACILITY ID Al APPROVED BY NAME PHONE N WITH AREA CODE t/ f-LF_ to PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOTION CODE CENSUS TRACTI! SUPERVISOR-DISTRICT LODE BUSINESS E N❑FILED NO DATE F, q r CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: v'^, Ems, THIS FORM MUST BE ACCOMPANIED BY AT LEAST Ill OR MORE TANK PERMIT FORM 'B'APPLICATION(S), U °SS THIS IS A CHANGE OF SITE INFORMATION ONLY. ORM �'l )