BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `AI: UNDERGROUND STORAGE TANK PROGRAM ="term Z 0 SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , l o C COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE IJ ONE ITEM ❑ p INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE po I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/BITE NAME , CARE OF DDREBS INF RMATION Golelli ckl Ec�uzl/t16 o�LJ4rINa0Mll=DUAL ADDR r NEAREST CROSS S ❑ PAWNEASNIP ❑ STATE AGENCY ❑ LOG1l-AGENCY ❑ FEDERAL AGENCY Va( ❑ CUUNn-AGENCYCITY NAMSTATE E PHONE N.WITH AREA CODE CA 0 TYPE OF BUSINESS p DISTRIBUTOR 4 PROCESSOR //Box if INDIAN EPA ID N _ N of TANK'N ESE [--II GAS STATION ❑3 FARM 55J.SOTHER TRUSTVATION LANDS or El IAT THIS SITE J EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) 1— MF(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE G�FeI p� 2oq-y6r_ asz6 NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE N WITH AREA CODE -lelli 269- II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME Gefyo/li '�G / CARE OF ADDRESS ce&zvr ORMATION_6111, MAILING or STREET T ADDRESS�NM` JNA I ✓Co.to ind¢ate ❑lPPPARTNERSHIP ❑ STATE-AGENCY 6 ❑ RA ION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY INDIVIDUAL Cl COUNTY-AGENCY CITU NAME TATE CODE PHONE p.WITH AREA CODE k C �f5zo S III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAM CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to,rd,cate Cl PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,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. ❑ litz 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 AGENCYAI FACILITY ID Al M of TANKS at SITE a 101011 D S 1(010101 / V CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE 60TEL 16 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT M SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DA±Lj 23 ,4S0 'Z YES NOCHECK N PERMIT AMOUNT SURCHARGE AMOUNT4. FEE CODE RECEIPT N 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 ONLYr - FORM A(3-2-88) ' DATA PROCESSING COPY �„�el