BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD 5 'M1f w FORM TAI: UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION : COMPLETE THIS FORM FOR EACH ACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION LY 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 S L� o s4m ADDRESS RION 0AGENCY ),? NEAREST CROSS STREET ❑ PARTNET&W ❑ STATE MENCY OMA` O CW AGENCY REACOOE CITY NAME STATE ZIP c0% SIM ll/'p yll TYPE OF BUSINESS. ❑ [:]2 DISTRIBUTOR 4 PROCE R ✓Box if INDIAN EPA IID N 9x'77If of TTANK's /) ❑ 1 GAB 6TATIDN ❑ 3 FARM ❑ 5 OTHER TRUSTRESERYATION IANDS or ❑ AT THIS SITE V EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAM ST FIRST) ;F04HOyF N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS. NAME(LAST,FIRST) r PHONE NN WITH AREA CODE NIGHTS: NAME ST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION G3�i'!^e a1i 7 MAILING or STREET ADDRESS ✓Box t°md,i ate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION D 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 Z CARE OF ADDRESS INFORMATION Gx^> MAILING or STREET ADDRESS ✓Box to inoicale ❑ PARTNERSHIP ❑ STATE-AGENCY O CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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: I. ❑ if. ❑ 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 k FACILITY ID R B of TANKS M SITE CURRENT LOCAL AGENCY FACILITYN f�O APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATON CODE CENSUS TRACT 8WERVISOR-018TRICT,CODE BUSINESS PLAN FILED DATE FILED YES NO CHECK N PERMIT AMOUNT SURCHARGE AM—ODNT ` FEE CODEtzlRECEIPT k 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(3-2.68)