BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

�F STATE OF CALIFORNbD ' WATER RESOURCES CONTROL BOARD FORM 'A': V �'T UNDERGROUND STORAGE TANK PROGRAM o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE cn 1. FACILITY/SITE INFORMATION &ADDRESS -(MUST BE COMPLETED) e) FACILITY,ISITE NFME CARE OF ADDRESS INFORMATION ATE ADDRESS NEAREST CROSS STREET COLO TION ❑ LAIF 0 OCALAGENLY D OiEOEPU Ai !76 er INDMIDUAL D COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE s,WITH AREA CODE PAI �Ls l/� TYPE OF BUSINESS 2 DISTRIBUTOR d PROCESSOR ✓Box 9INDIAN EPA ID a It of TANKs ❑ ❑ 50TMER RESERVATION or ❑ AT THIS SITE I ❑ 1 GAS STATION 3 FARM ❑ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME HAST.FIRST) PHONE if WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME - CARE OF ADDRESS INFORMATION se!'T1/G�s I MAILING or STREET A DRESS / ✓Sox to indicate D PARTNERSHIP D STATE-AGENCY , D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY (O D INDIVIDUAL D COUNTY-AGENCY GIN NAME ST61E ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) D) COO/,MPLETED) NAM CARE OF ADDRESS INFORMATION MAILING or STFIEET ADDRESS ✓Box to indicate ❑ PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOA INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11.0 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY S JURISDICTION R AGENCY X FACILITY ID R N of TANKS N SITE ffalI I 141 / CURRENT L CAL AGENCY FACI ITY ID M APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI ED YES ❑ NO CHECKS PERMIT AMOUNT SUIRCHARGII AMOUNT FEE CODE RECEIPT lim 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. 'V1 I FORM A(3-2-86) 1 u �... DATA PROCESSING COPY `f