BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA'' WATER RESOURCES CONTROLZOARD ''�` ` FORM .A,; (%�> , ';, UNDERGROUND STORAGE TANK PROGRAM =" a SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; 10 COMPLETE THIS FORM FOR EACH FACILITY/SITE `'�� "—`" MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMWENTLY CLOSED SITE I'A' ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE rtp I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) -4 A FACILITY/SITE NAMECARE OF ADDRESS INFORMATION N) AcN A �? 0— kAjo ADDRESS NEAREST CROSS STREET miole ❑ PARTNERSHIP ❑ STATE AGENCY Lf 00 (� U COROIUTION 11LOCAL AGENCY ❑ FEDERAL AGENCY —I V INDNIWAL ❑ UUnAGEND' CITY NAME `�Y STATE ZIP CODE SITE PHONE p.WITH AREA CODE A / TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑1 ESSO\RR ✓IBBoox if INDIAN EPA IID # VX of TAN82MN E] 1 GAS STATION ❑ 3 FARM 5 OTHER TRUST(LANDS VATION or ❑ 1 AT THIS SITE 6 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE e Fle -9$2 2 Acv NIGHTS NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME Q CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS I/Box teintllcate ElPARTNERSHIP ElSTATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME /� CARE F ADDRESS INFORMATION NIII MAILING or STREET TRESS �/ to ird,cat ❑ PARTNERSHIP CISTATE-AGENCY //�� CORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY _ t 0 R O 0 ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAMES-rK I STATE - ZIP E PHONE N.WITH AREA CODE CI IV. LEGAL NOTIFICATION AND BILLING ADDRESS Y/'T� S CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ 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 COUNTY X JURISDICTION X AGENCY X FACILITY IDX N of TANKS at SITE ® � IoDI / O o () oIE- CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE MANNAg0 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED PATE FILED ry q 11 1-03 SO Iffifu YES ❑ NO ❑ CHECK PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY:wf 1� 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(3-2-88) �� DATA PROCESSING COPY 1.0w,