BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

/^Oi'' STATE OF CALIFORNIX WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM =" o z SITE RR/ FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ea ^,ioa ,P COMPLETE THIS FORM FOR EACH FACILITY/SITE - MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENT SITE O ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE O,F DRESS INFORMATION J NEAREST OSS STREET ia,mule 0 PARTNERSHIP Cl STATE AGENU ADDRESS ^ /'.I� / APORATION Cl COUNTY AGENCY ❑ FEDERAL AGENCY •/ NI ��iLMO� X^"_,v l ❑ COUNIYAGENLY Cl NAME STATE ZIP CODE SITE PH NE X,WITH AREA CODE Uz CA S"23 `► 2Dq TYPE OF BUSINES 2 ISTRIBUTOR 4 PROCESSOR ✓Box d INDIAN EPA/ID�9 X of TANK'X ❑ 1 GAS STATIO 3 FARM ❑ 5 OTHER TRUST LANDS ATION or 1:1 (iv AT THIS SITE DO EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) GAYS: NAME(LASTAREA,FIRST) PHONE X WITH EA CODE DAYS'. NAME(LAST,FIRST) PHONE 4 ITH AREA CODE NIGHTS'. NAME(LA T.FIRSTS PHO@ ITH AREA CODE NIGHTS: NAME(L T FIRST) PHONE AREA CODE ,A II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME " // -r CARE OF ADD ESS INFORMATION MAI G or STREET MRESS ✓ to indicate El PARTNERSHIP ❑ STATE-AGENCY D, (CJgr CORPORATION ❑ LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME /'t?� STATE ZIP CC3,23-7 HONE X,WI H AREA CODE sell III. TANK OI LWNER IN RMATION & ADDRESS - (MUST BECCOMPLETED) NAME r A / CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS) (j-��✓(J fq/"'�O•/ ✓Box to indicate ❑ PARTNERSHIP D STATE-AGENCY D CORPORATION Cl LOCAL-AGENCY D FEDERAL-AGENCY 0 INDIVIDUAL D COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE X,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. E, 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 R JURISDICTION N AGENCY X FACILITY ID At If of TANKS at SITE m = ° (-/ zz I J 0 � CURRENT LOCAL AGENCY F LITY ID N APPRn �B�'NAM �� PHONE X WITH AREA CODE 1F 5 PERMIT NUMBER C 2 PERMIT APPROVAL DATE [/ !j PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT X SUPERVISOR-DISTRICT CODE BUSINESSPLAN FILED DATE FILED YES NO Z'j CH X PE T AMOUNT •d" SURCHARGE AMOUNT FEE CODE RECEIPT X 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 FOF�M A(3.2-88) �- V law DATA PROCESSING COPY `r/