BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

. ..pT .ffr.;T +a+.VI�RyPIw'^vw.-.w'.s�e4 . .,- y^r�".Wf,".e,`E-. ,r -,EA,r .. :;n,yikTryv" I STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD �s FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE ; FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE °"•se"`� EO MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT DXCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE C1 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAMECARE OF ADDRESS INFORMATION 5-54-72005-54-7200a S00 " ADDRESS NEAREST CROSS STREET ✓Bor to mekak [I PARTNERSHIP [I STATE AGENCY U^� ❑ FAR��tt44TION C LOCAL ❑ FEDERAL AGENCY &dAA� C COUNTY AGENCY CITY NAME L,, STATE ZIP CODE SITE PHONE ft,WITH AREA CODE 1�12GL/ CA TYPE OF B ESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID a RESERVATION or N of TANK'Y 1 GAS STATION ❑ 3 FARM ❑ 5 OTNEfl TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS N E(LAST,FIRST) PHONE a WITH AREA CODE DAYS'. NAME(LAST.FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAM (LAST IRST HONE X WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREE DRESS ✓Bax to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ��//��r/] // C CORPORATION 11LOCAL-AGENCY ElFEDERAL-AGENCYI J1,4 FL ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODENE A,WITH AREA CODE PHO y 1fA5 III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP C STATE-AGENCY Cl CORPORATION ❑ LOCALAGENCYCl FEDERAL-AGENCY ❑ INDIVIDUAL C COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ I. 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION S AGENCY N F If of TANKS BI SITE CURRENT LOCAL AGENCY FACILITY ID NPROVED BY NAME PHONE k WITH AREA CODE OBIL 10 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUSTRI Kl SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE LED �3 -OV YES NO 7 CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M Y: `I THIS FORM MUST BE ACCOMPANIED BY AT LEAST(a'-R MORE TANK PERMIT FORM 'B'APPLICATION(S), UNL«A THIS IS A CHANGE OF SITE INFORMATION ONLY.f `1 FORM A(3-2-88) (w 11111. DATA PROCESSING COPY � \\u