BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL�ARD , A FORM A: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION R9j COMPLETE THIS FORM FOR EAC ACILITY/SITE MARK ONLY F-11 NEWPERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 10 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME ( CARE OF ADDRESS INFORMATION S 5 v pN i:7 ADDRESS ^ NEAREST C$OSS STREET ✓Bax to wrote 0 PABTNENSHIP ❑ STATE-AGENCY i 1`x(7 O n� I . I 0 CORPORATION 0 LOCAL-AGENCY 0 FEDEMLAGENIX N "` F� W l ❑ INDrvIouAl ❑ couNn ncENc � CITY NAME C J�/- - STATE ZIP CODE SIT PHONE tt,WITH AREA CODE I/c/i III TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK'S ❑ 1 GAS STATION ❑ 3FARM THEfl TRUSTATION LANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS' NAME(LAST,FIRST) PHONE#WITH AREA DE� DAYS'. NAME(LAST EST) PHONE p WITH AREA CODE V C I NIGHTS'. NAM (LAST.FFR ) PHONE#WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE S It. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME L CARE OF ADDRESS INFORMATION l�I MAILING or STREET AD RESS ✓ed indicate ❑ PARTNERSHIP D STATE-AGENCY 1 OPRORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 22 � J INDIVIDUAL 0 COUNTY-AGENCY CITY NAME n -7w 1 , rO I STATE ZIP CODEPHONE 0,WITH AREA CODE CA III. TANK OWNER INFORMATION &&ADDRESS — (MUST BE COMPLETED) NAME t-- CARE OF ADDRESS INFORMATION . ill�l� MAILING oil STREET A DRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 2 O 0 INDIVIDUAL 0 COUNTY-AGENCY CITU NAMECxT� � CA — IV. ZIP CODE PHONE p.WITH AREA CODE J ( � _ 9s�Zo 6 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IU ❑ If. ❑ 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# AGENCY# FACILITY ID# If of TANKS at SITE LZ I /1010 IV- 1 101010 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE Al WITH AREA CODE AL /( PERMIT NUMBER PERMIT APPROVAL DATE - PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PU1N FILED DATE FILED p� YES NO ❑ i b L PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# SY: 'I / ✓V 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. FORM A(3-2-8B) l.. DATA PROCESSING COPY 'R•' )