BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA---' WATER RESOURCES CONTROLL.dARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE / , FACILITY/SITE, INFORMATION and/or PERMIT APPLICATIO : C/ COMPLETE THIS FORM FOR EAC AGILITY/SITE C MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWALPERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1 I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAMEfiU5 eU71J CCARE OF ADDRESS INFORMATION ADDRESS V NEAREST CROSS STREET 1. 11 PARTNERSHIP El STATE-AGEfVMO ❑ G-AGBC ❑ FEDERAL d " - NdU5'Ip4L/ Yp OCI MAL ❑ COUNTY-AGI w I CITY NAME STATE ZIP CODE / SITE PHONE*.WITH AREA CODE CA SS /V TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PBPCESSOR -/BOX if INDIAN EPA ID N RESERVATION or ❑ N of TANK's ❑ 1 GAS STATION ❑ 3FARM OTHER TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST.FIRST) PHONE Al WITH-(RDAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE AlCegCc 2°9 EA CODE 26 NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST IRST) PHONE N WITH AREA CODE l( )? 0 // D -W-517VI II. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION U t4 i me V ic-f_ 5A (i 6eR MAILING or STREET ADDRESS c n r^ ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY 13 I S?EB-r�o ❑ CORPORATION LION ❑ COUNTY-AGENCY AGENCY ❑ FEDERAL-AGENCY CITY NAME des}�a STATE ZIP CODES PHONE F.WITH AREA CODE Mo Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED)) NAME I CARE OF ADDRESS INFORMATION VN fWP_5AL ?� t* PrzioitI 144, MAILING or STREET ADDRESS I/BOX to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY J1 ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY Q V ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITYNAME STATE DECODE 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: I. ❑ II. ❑ 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 M JURISDICTION k AGENCY N FACILITY ID Al N of TANKS at SITE [91 16D D / DCII CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE M WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT* SUPERVISOR-DI TRICT CODE BUSINESS PUN FILED DATE FILED 0 / a L/ ODE NO Z F� CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* BY:d / I 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 IIT FORM A(3-2-SB) A4� DATA PROCESSING COPY Ally"