BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM W: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH! CILITY/SITE MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL95EP SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE F6 3 I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACIUTYBRE NAA ] CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓L lioditae ❑ PAATNE"IIP ❑ STATE-AGENCY ❑ COW04TION ❑ LOC#AGENLY Cl FEOEALLAGDIV N ❑ IADMWAL ❑ OOONTYAGENCY CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE C CA d TYPE OF BUSINESS: 2 DI OR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID# RESERVATION or ❑ #of TANK'# ], ❑ 1 GAS STATION FARM ❑ 5 OTHER TRUST LANDS AT THIS SITE I EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST, IRST) , PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE Sa A" x,,y/`e-- II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP D STATE-AGENCY O CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ 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: 1. ❑ I. ❑ 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 d SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION# AGENCY R FACILITY ID# R of TANKS at SITE M I 10SDG l CURRENT LOCAL AGENCY FACILITY ION APPROVED BY NAME PHONE N WITH AREA CODE ❑<iG, PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTIAICT CODE BUSINESS PLAN FILED DATE F O �� 3 a a YES � NO �L , CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST SE ACCOMPANIED BY AT LEAST(1)OR MORE TAM(PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88)