BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ..... FORMW: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION `, 1 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMITCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Fzrct I- 10 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION N ADDRESS NEAREST CROSS STREET ✓Boxbirdirate ❑ PARTNERS IF ❑ STATE.AGENCY (D ❑ CORPORATION �.iBBI[AfEKY ClFEDEAALAGENCY ❑ INDIVIDUAL ❑ COUNIBAGENCe CITY NAME IF STATE ZIP CODE SITE PHONE#,WITH AREA CODE 010 dt-11 CA 6 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR 4 P OR ✓Box if INDIAN EPA ID a RESERVATION or #of TANK's ❑ 1 GAS STATION ❑ 3 FARME&R-fOTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: VyE(VAST,FIRST) PHONE#W AREA CODE DAYS. AME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS'. NAME LAST. RST) PHONE#WITH AREA CODE NIGHTS. NAME ST FIRST PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDR ✓Box to indicate ❑ PART��fifiRP3311i1IP ❑ STATE-AGENCY ❑ CORPORATION at:f1C.AL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY.AGENCY CITY NAME STA I ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFOR ION &ADDRESS — (MUST BE COMPLETED) NAME -"�'/'Y CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS %/Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY 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. ❑ If. 111.❑ 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 COUNTYIN JURISDICTION If AGENCY# FACILITY ID a a of TANKS at SITE [K�l = = lo III I t -71 / 10 lo 10 11 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE O PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED / YES NO ❑ `?-;111 CNE # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE 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 ONE FORM A 13-2-88) .� DATA PROCESSING COPY