BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFOR4�) WATER RESOURCES CONTCe BOARD z` FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION F m o COMPLETE THIS FORM FOR EACH CILITY/SITE `'A��oa�"' MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMA NTLY CLOSED SITE ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 N 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) O FACILITY/SITE NAME �'V7 Q CARE OF ADDRESS INFORMATION CD ' 7470NAN ADDRESS f / N ARESTCROS STREET ✓ bMb2 ❑ PARTNOMP ❑ STATE AGENCY MWOUTION ❑ LOCALAG90 ❑ FEDENALAGM INDIVIDUAL ❑ coun AGENCY CITY NAME C �0 STATE ZIP CO SITE PH qlE W17H ARBA CO E CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑d SSOR ✓Box H INDIAN EPA IDN `!,/V^ Nol(Ti/At/N1K16 Q/ ❑ I GAS STATION 3 FARM 5 OTHER RESERVATION or ❑ TRUST LANDS ❑ AT THIS SITE O EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) GAYS AMIE(LAST,FIRST) PH R/�L ,q ONE ITH AR6EA2CODE DAYS'. N (LAST,FFIIIRRSSIT)LAO vj ) // PHON6p61TH AARREA CODE NIGHTS: NAME(LASIT FIRST)V b r� HON WITH AREA CODE NIGHTS'. E T.FIROT) / ��PHONE p WITH AREA CODE 5WMA_ 6/ ,S II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME QQl +A CARE OF ADDRESS INFORMATION MAILING or STREET ADDREt �. /1 emto indicate 0 PARTNERSHIP 13STATE-AGENCY 114- N/./„�vV_ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY ❑ INDIVIDUAL 0 COUNTY-AGENCY CITY NAMETATE ZIP CODE/ PHONE p WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME ”' CARE OF ADDRESS INFORMATION tj MAILING or STREET ADDRE ��fff k�w -indicate Cl PARTNERSHIP 0 STATE-AGENCY 0. CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY / V 1 [i 0 INDIVIDUAL 0 COUNTY-AGENCY CIN NAME STATE ZIP CODE PHONE N,WITH AREA CODE S70GlL7ou 4�A_ cfs'20/ Z IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. 'i APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION R AGENCY R FACILITY ID R A of TANKS At SITE PTI-1 = = 1010130 oov CURRENT LOCAL AGENCY FACILITY ID 5 ' APPROVED BY NAME PHONE M WITH AREA CODE S7Z? '/ 1_ 6 PERMIT NUMBER PERMIT APPROVAL DATE c PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRAAC�T F SUPERVISOR-DIS�CT CODE BUSINESS PLAN FILED DATE FILED 0 / Z3 O d YES NO CHECK F PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N BY: ' THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. /FORM A(3-2-88) I /I/ DATA PROCESSING COPY `1