BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM ito SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION j COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERM LOSED SITE PV ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Q' CSi I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAMECARE OF ADDRESS INFORMATION Q ADDRESS NEAREST CROSS STREET ✓ Bo mi 11 PARTNERSHIP ❑ STATE AGENCY ARRORATION ❑ LOCAL AGENCY ❑ FEDERALAGENCY INOIVIOUAL ❑ COUNTY- AGENCY CITY NAME STATE ZIP CODE SITE P NE p,WITH AREA CODE CA ZZY� 09 �61-Zs:- TYPE OF BUSINESS p 1STRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA'10 a IF of TANK's ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER TRRUSRYATION LANDS or ❑ N AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS' ANAME�(LAST.FIFIR�ST)) PHO E N WITHgAREA CODE DAYS c�N ME(LAST,FIRST) PHONY If WITH AREA CODE If NIGHTS'. NAME(LAST,FIRST) HONE N WITH AREA CODE NIGHT�gAME(LAST,FIRST) PHr/p WITH AREA CODE S /AA Tl II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME `. CARE 0 ADDRESS INFORMATION R. A MAILING or STREE DDRESS ✓Box to intlicate ❑ PARTNERSHIP ElSTATE-AGENCY p,YJry/I 1 ❑ ORPORATION ❑ LOCALAGENCY LlFEDERAL-AGENCYZbD WW+ LN INDIVIDUAL ❑ COUNTY-AGENCY CITY NAMt O� A STATE ZIP CODE PHONE 4 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 ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4 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. 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# JURISDICTION Is AGENCY# FACILITY ID Is #of TANKS at SITE Eal 10o 1 v vDo0 CURRENT LOCAL AGENCY FACILITY ID If APPROVED BY NAME PHONE At WITH AREA CODE PA PERMIT NU BER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIOjI_CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PELSN FILED NO CHECK �AE� I (#( PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `S'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. I FORM A(3-2 ) C - �i DATA PROCESSING COPY � \V\1