BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM 1 �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Z G , COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 1 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION r ADDRESS NEAREST CROSS STREET ✓ftvIr mie DA/II PNERB9IP D STATE AGENG! S 11INNDIVND W DX UNTY-AGENCY ❑ RDEML AGENCY I CA IP COD CITY NAME STATE ZE SITE PHONE q,WITH AREA CODE �j TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR RESERVATION oxitINDIAN EPA ID a Mat TANK'S /J ❑ 1 GAS STATION [:] 3 FARM ❑ 5 OTHER TRUST LANDS ❑ I ATTHISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toindicate D PARTNERSHIP ❑ STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE M.WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS %/Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY Cl INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,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. ❑ II. ❑ Ill.❑ 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 MMMMMMMM COUNTY N JURISDICTION R AGENCYA, FACILITY ID S If of TANKS at SITE s I s9 1 1 1 1 10 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT P SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILFD 2-5 .71 3 YES ❑ NO ❑ -+/z& q0 CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEECODE RECEIPT A 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. J y N FORM A(3-2-8B) /y DATA PROCESSING COPY VI.F 0