BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORMW WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONS Io COMPLETE THIS FORM FOR EACH FACILITY/SITE I MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT Evf5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I"4' ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE i I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓ loilgicap 0 PARNERSHIP 0 STATE AGENLY CORPORATION 0 LOCALAGEIV 0 FEDOALAGM S 11INDIVIDUAL 11CGUWAGENCY CITU NAME STATE ZIP CODE SITE PHONE Jr.WITH AREA CODE �CA CA 533 TYPE OF BUSINESS 2,D6fRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # ❑ 7 GAS STATION 3 FARM ❑ 5 OTHER TRUSRESETATION LANDSor ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE M WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILINGor STREET ADDRESS /T ✓ ox to indicate 0 PARTNERSHIP 0 STATE-AGENCY 3 CORPORATION 0 LOCALAGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STAT ZIP ODE PHONE a,WITH AREA CODE 533 III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION E MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CIN 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. ❑ 11. V1 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 a JURISDICTION R AGENCY k FACILITY ID Ir If of TANKS at SITE =1 I I 14 103 CURRENT LOCAL AOJgY FA ILITY 10� A APPROVED BY NAME PHONE k WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOC TION CODE CENSUS TRAC a SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED ❑ DAT FIL O 3 I/(/^ VES NO ic-cl CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT At 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. FORM A(3-2-M) Illin/ DATA PROCESSING COPY `F