BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNW WATER RESOURCES CONTR BOARD ''E"•�"'�'`° FORM IA': UNDERGROUND STORAGE TANK PROGRAM V Tho SITE n FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , Li COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY Vml NEW PERMIT ❑ 3 RENEWALPERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE PJ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 2i I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) N FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Q �s,_�7 i 1yaiY 4�k 1YD�f/ ADDDRREESS� NEAREST CROSS STREET ✓80,m icit, ❑ PARTNERSHIP ❑ STATE AGENCY ❑ INDIVIDUAL ❑ CWNNEl �NCy ❑ fEGEML-AGENCY CITY NAME STATE ZIP DOW SITE PHONE A.WITH AREA CODE .S�r�G-rT1J/� CAo7O1--7- TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Bax if INDIAN EPA ID a ❑ ❑ ❑ TRUSTYLANDS or ❑ C�L ��3 AT THIS SITE I GAS STATION 3 FARM 5 OTHEfl EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYSNAME(I-AST,FIRST) PHONE N WITH AREA CODE DAYS' NAME(I-AST FIRST) PHONE It WITH AREA CODE oliz7/✓/Sc! z /la// f- �tiZ�loc7 1;��l NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(I-AST,FIRST) PHONE It WITH AREA CODE LIT/ R/C//Z7� Mv crjfwp_lw�z_ II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION rs �Usk ,•- � MAILING or STREET ADDRESS r Box to indicate Cl PARTNERSHIP El STATE-AGENCYCORPORATIj �� //�,!/ El INDIVIDUALON 11 COUNTY-AGENCY 11 LOCAL AGENCYCIFEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE B,WITH(/AREA CODE S%A( 0,Q�ary 3 III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE F ADDRESS INFORMATION ��+P'' � MAILING or STREET ADDRESS ox to indicate ❑ PARTNERSHIP Cl STATEAGENCY 9 CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITU NAME (�W STA ZI 0 PHONE It,WITHAREA 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. ❑ it. ❑ Ill.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S N RI NATURE DAT 9A LOCAL NC O COUNTY X JURISDICTION K AGENCY N FACILITY ID N If of TANKS at SITE CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE evr_ PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TjlACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED /' 26 . OZ YES [—] NO G-{13 —/c) CHECK K PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M BY: K THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM IS'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ON FORM A(3-2,8`8) ice` L DATA PROCESSING COPY 1.4