BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM W: UNDERGROUND STORAGE TANK PROGRAM I �o SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE �'A�•oN"'" yy MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE L-I ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) W W FACILI /SITE NAME CARE OF ADDRESS INFORMATION W ADDRESS NEAREST CROSS STREET ✓NPW duW 0 PARTNERSHIP ❑ STATE-AGENCY v, F ❑ CORFO IATION ❑ LOCAL AGENCY ❑ OWL AGENCY INDVIDPL 0 COUNTY-AEUN CITY NAME STATE 21 CODE SITE PHONE p.WITH AREA CODE CA oZ05 3/'Ls TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ R PROCESSOR '/Box H INDIAN EPA ID x RESERVATION or If TANK'S ❑ I GAS STATION ❑ 3 FARM HER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME(LAST.FIRST) PHONE*WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE (ao9) ,?3 /-GS NIGHTS: NAME(LA ,FIRST)n �. ^ PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE W/,lam II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME Is CARE OF ADDRESS INFORMATION MAI or ST ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 'J'J�� 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERALAGENCY • 01 V O 0 INDIVIDUAL 0 COUNTY-AGENCY CITY N ME� STATE ZIP COOS P O E9 WITH AREA CODE III. TANKOWNERINFORMATION &ADDRESS— (MUST BE COMPLETED)) NAME /' CARE OF ADDRESS INFORMATION O— - MAILINNGOF.STRE DRE ✓Box to Indicate ❑ PARTNERSHIP 0 STATE-AGENCY 4 ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME_ V STATE ZIP CODE PHONE p.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. Il. ❑ 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 N JURISDICTION k AGENCY R FACILITY ID R R of TANKS at SITE 3C� � � 0 1 s moo CURRENT LOCAL AGENCY FACILITY IDR APPROVED BY NAME PHONE p WITH AREA CODE PERMITN BE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE ±OCATNDE CENSUS TRA # SUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATEF EYES ❑ NO //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 IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-8R) DATA PROCESSING COPY