BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

m STATE OF CALIFORNIA-- WATER RESOURCES CONTROL'dOARD a ' FORM A: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EAC FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT FO 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 5iX G ,.I ADDRESSNEAREST GROSS STREET ✓Boob itliule 0 PART*RW D STATEAGPN6Y El07WGMTCN D LOGIAGDo 0 ff E AGENCY S', �I 0 ININIGGAL 0 CGM1Y.AGENLp CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE ick+oN CA (isao 6 TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID 4 flESERVATION or #of TANKY ❑ 7 GAS STATION ❑3 FARM ❑ 5 OTHER TRUST LANDS ❑ 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 N WITH AREA CODE 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 CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to inoiwte D PARTNERSHIP 0 STATE-AGENCY D CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY D INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.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: 1. II. ❑ 111. ❑ 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 R AGENCY R FACILITY ID R N of TANKS at SITE " 5 CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE s;r \� PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT; SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FEJED �(� ZS YES NO ❑ l`' 90 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT; By.. THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS 18 A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-B)