BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONOOL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM " Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to COMPLETE THIS FORM FOR EACH FA LITY/SITE MARK ONLY ❑ I NEW PERMIT ❑3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY SITE CLOSURE 00 I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) N FACILITY/SITE NAME CARE OF ADDRESS INFORMATION /f lis- n ADDRESS {I / NEAREST CROSS STREET ✓ ❑ P ❑ STATEA090 CY-711 ODWMT ffAM13FE)ERLLLMDI J ❑ NOMDUAL ❑ MWTYAMCV CITY NAME STATE ZIP CODE SITE PHONE#.WITH AREA CODE CA Z51201 TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 ✓Bdx i'INDIAN EPA ID N / k S of TANK's ❑ I GASSTATION ❑3FARM OTHER RESERVATION or u ❑ — AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(UST FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE Ate 4171041,1,171 NIGHTS: NAME(LA RRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE C7 �_ II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION n 17Q 9 SS MAILING or STREET ADDREJF ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION 11LOCAL-AGENCY13FEDERAL-AGENCY rkAA/ Oq !/7„O 13INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 01,WITH AREA CODE vk &/� III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION 6 ✓e MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. IK if. ❑ III.E7171 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# �JURISDICTION II 1 AGENCY# FACILITY M# #of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE NTD/V PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED p 3" 36)3 YES [-] NO ❑ / —dl CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT# 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(3-2-89) _ O, �1 .� y ` �^- DATA PROCESSING COPY