BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

jTATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ` FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 0 �� Io COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE F-k ONE ITEM ❑ p INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE N ME CARE OF ADDRESS INFORMATION /d 14,040 tit m Cl/ egii 6v f1ibans- ADD SS NEAREST CROSS STREET ✓Sto,towese ❑ PARTNERSHIP ❑ STATE AGENCY /p //,_Sf ClCOWOM70N ❑ LOCAL AGENCY ❑ FEDERAL- AGENCY LZ INDNIOUA( ❑ couNn-Aama CITY NAME / STATE ZIP CODE SITE PHONE IT,WITH AREA CODE CeY IA( CA 5a2v 6 har,Ee ��.rs� TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a EZ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TgIS1ST LANDS TION dr ❑ AT HIS SITE 3 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) YS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE ft WITH AREA CODE NIGHTS'. NAME(LA FIRST) PHONE IT WITH AREA CODE NIGHTS'. NAME(AST,FIRST( PHONE It WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING r STREET ADDRESS 33y ,� 0;e_, ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY jff INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE 6 4Se2e5 III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION lezy MAILING or STREET ADDRESS, ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY INDIVIDUAL ❑ COUNTY-AGENCY CITU NAME STATE ZIP CODE PHONE It,WITH AREA CODE f C4. 7-5-24:wQsG�8 7 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.IK III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTE SIGNATURE) DATE b—5- LOCAL AGENC USE ONLY COUNTY R JURISDICTION S AGENCY B •of TANKS at SITE 39 ,;� I 4 y10o I 03 CURRENT LOCAL AGENCY FACILITY ID x APPROVED BY NAME - PHONE Jr WITH AREA CODE WCV r, PERMIT NUMBER IIEFIMIT APPROVAL DATE PERMIT EXPIRATION DATE LCHECK# CENSUS TRACT k SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 23. 6 3 2 S- YES ❑ NO W$ztjPERMR AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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 ONLY. 'ORM -2\v ,� ' "1 DATA PROCESSING COPY /