BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN6v WATER RESOURCES CONTROeBOARD W: FORM `A': UNDERGROUND STORAGE TANK PROGRAM �o S�T FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION id ' N COMPLETE THIS FORM FOR EACH ACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT r 5 CHANGE OF INFORMATION ❑ 7 PERMANENTI I LOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) FACILITY/SITE NAME ` CARE OF ADDRESS INFORMATION R c, ADDRESS NEAREST CROSS STREET ATE AGM 2_5 TION ❑ LARTNERSHIP 0 OCALAGDAN ❑ �IMMAGEA0 a N, u ❑ ODU IYAGENCY CITY NAME Y V T STATE ZIP CODE SITE PHONE M.WITH AREA CODE CA C Q d TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ d PROCESSOR ✓Box if INDIAN EPA ID N N of TANK' ESE ❑ 1 GAS STATION ❑3 FARM Ej;JeHER TRUSTVATION LANDS Or ❑ ^✓f/v��^ p�� ATTHISSRE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PH NE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE If WITH AREA CODE ao9 9Y?a 9 to NIGHTS. NAME LASe FIRST)I PFTONE k WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE If WITH AREA CODE S II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING w STREET ADDRESS ✓Box to inEioate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE Ill. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME _� CARE OF ADDRESS INFORMATION a MAILING or STREET ADDR S �• ✓Box to irmicate El PARTNERSHIP El STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY (j CITY NAME � � ST/yTE� ZIP CODE / PMoao WITHTH ARE ^ Ll ��D IV. LEGAL NOTIFICATION AND BILLING ADDRESS C CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ If. ❑ 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 X JURISDICTION k AGENCYIN FACILITY ID R R of TANKS M SITE " ® = = 161 o I t[�= I 1 1131 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE F WITH AREA CODE a a- PERMIT NUMBER PERMIT APPROVAL DATE PERMR EXPIRATION DATE LOCATION DE CENSUS TRAC M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED i YES NO ❑ �' CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: I _I 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)