BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM A : UNDERGROUND STORAGE TANK PROGRAM SITE / FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION TLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS ^ .J.l_ NEAREST CR SSSTREET ✓ftlo nle Cl VAAi YOWIP ❑ STATE-AGENCY DD IIWWAII� O CO.AFY-AGENCY ❑ IDEM AGD CITY NAME STATE ZIP CODE SITE PHO E M WITH AREA CODE 7� CA e 93s'b3Z TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box ii INDIA EPA ID N Rol TANICN ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUSTVLAND$or ❑ AT THIS SITE V 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 M WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D 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 md,.We D PARTNERSHIP D STATE-AGENCY Cl CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDREBB SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ 11. ❑ 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 A SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY M JURISDICTION M AGENCY R FACILITY IDM M of TANKS at SITE I E= U CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE S PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LLOCAnONCOHSE CENSUS TRACT N SUPERVISORR--DISTRICT CODE BUSINESS PLAN FILED DATE FILED / 23�d `7]�y YES NO � 'q—�Z_PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N 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. FORM A(3-2-8B) � (� `1 YP�{ '\ ,"� I ``