BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

c_,m'+am.•^r. .. S`. _ �wiww"°4; m�iH15�Y ..0^�T.'wnyltl.e-x s .r.x _ STATE OF CALIFORNIA- WATER RESOURCES CONTROL,. 1ARD """ `` FORM 'A': UNDERGROUND STORAGE TANK PROGRAM o Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION o to mi COMPLETE THIS FORM FOR EACH FACILITY/SITE ""�°"`� MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ® 7 PERMANENTLY CLOSED SITE F"'A ONE ITEM ❑2 INTERIM PERMIT ❑ 1 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) W � FACILITY/SITE NAME CARE CF ADDRESS INFORMATIO"- �N K ev N USA i ADDRESS NEAREST CROSS STREET ✓BmbnOiob D PARTNERSHIP D STATE AGBIGY l0/ ° ° `OA ° � A "G°C C ec tol-' I D I�X D CM CITY NAMESTATE ZI s2y� n do NE p.WITH AREA CODE /N / CA TYPE OUSMESS: ❑2 DISTRIBUTOR ❑/QESSOR -/Box R INDIAN EPA ID p N of TANK'N Em 1 GAS STATION ❑3 FARM ❑5 OTHER TRUSTYLANDS m ❑ U Nv AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) /, PH E p WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE p WITH AREA CODE WOIj'+kaAKAe, yrs 8�'H7-az-Yv uN NIGHTLY/NAAME� T) D %CH-DNI WITH ,2C, DE NIGHTSN NAME(LAST,FIRST) PHONE A WITH AREA CODE II. PROPERTY OWNER INFORMATION III ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION c4ev/^mo 6('54 Nc e MAILING or STREET ADDRESS ✓Boz toinEicple D PARTNERSHIP D STATE-AGENCY S/•-�c ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY / U M�(]� D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE SCY,LA FTz7,A '(SC6 C14 1 qVIO-5- 03 5V9 III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAMECARE OF ADDRESS INFORMATION Ifm67 AS d�N eh MAILING or STREET ADDRESS f ✓Box toinoicpte D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p.WITH AREA CODE 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. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION M AGENCY R FACILITY ID N B of TANKS N SITE ® Off / = 101010161 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DAN PERMIT EXPIRATLATE Vr LOCATION CODE CENSUSTI ACT N SUPE/RVIISSSC -DIDISTRICT CODE BUSINESS L DAM FILED02 2 0YESYES CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE BY: j 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. ORM A(3-2-88) < + ' DATA PR06ESSING COPY !1