BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA"' WATER RESOURCES CONTROL`!l6ARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION IZO COMPLETE THIS FORM FOR EACH„FACILITY/SITE eoaN`” MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PUMAUATLY CLOSEDSITE F..► ONE ITEM ❑Z INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) cn FACILITY/SITE NAME II ( CARE OF ADDRESS INFORMATION PENS AIAT-O ADDRESS �./n ` NEAREST CROSS STREET ✓Boxta irde ❑ PARINERSH? D STATE AGENCY J O ' )0 IZ^ D O RATION Cl LOLL AGENCY D FEDERAL AGENCY 1/ ,'7 NGM1'IWAL ❑ COUNTYAMD CITY NAME STkw STATE ZIP CODE _ � SITE P�_4'7FyAREACODE � TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDDIIAN EPA ID a S�O/vn /y//6 6 Z ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTVLANDS ATION o ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS VA'ME( ST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE It WITH AREA CODE U 101- 6 - 2 SG-vV-f NIGHTS'. NAME(I-A ,FIRST) `' PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 9 WITH AREA CODE p it II. PROPERTY OWN10 INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION QS MAILING or STREET ADDRESS ✓ to indicate D PARTNERSHIP D STATE-AGENCY ORPORATION D LOCAL-AGENCY ❑ FEDERAL-AGENCY VINDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME 5 CARE OF ADDRESS INFORMATION � MAILING or STREET ADDRESS ✓BcSteto Indicate D PARTNERSHIP D STATE-AGENCY RPORATION D LOCAL_AGENCY D FEDERAL-AGENCY INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIPCODE 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. l7f11. ❑ ITL❑ 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 K AGENCY R FACILITY ID R R of TANKS at SITE 31 = = 161D oFfo0o CURRENT L AL AGENCY FACILITY ID It APPROVED SY NAME PHONE A WITH AREA CODE PERMIT NUMBER P MIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED GATE FILED (� AV YES NO CHI PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M AY:_ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(i)OR MORE TANK PERMIT FORM B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL`/L� FORM A(3-2-88) \\J f vY. DATA PROCESSING COPY :^,-