BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

or .. STATE OF CALIFORNIA,- WATER RESOURCES CONTROL..OARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM ." o SITE / FACILITY/SITE, INFORMATION and/or PE MIT APPLICATION C� COMPLETE THIS FORM FOR EACH F ILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 P RMA SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE SpZ I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS Q �/fT NEAREST CROSS STREET ❑✓�CO�OMTNIII O lOfAIAT QIP s Ar>ErvcY 5/S� G+�. 6G7S�hesS ❑ INl�MM ❑ CWMAGENCY CITY NAME STATE ZIP CODE ' SITE PHONE p,WITH AREA CODE CA 13-3-7,41 3 3 TYPE OF BUSINESS'. ❑ 2 DISTRIBUTOR ❑ d PROCESWR ✓ ox if INDIAN EPA ID p A of TANK'S ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST YLor ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING w STREET ADDRESS ✓Box to Indicale 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY Cl FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING w STREET ADDRESS ✓Box to Indica(. 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p.WITH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ I. ❑ 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 R JURISDICTION B AGENCY N FACILITY IDR R of TANKS Al SITE p CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE p WITH AREA CODE PERMIT NUMBER n`fw) PERMIT APPROVAL DATE PERMIT EXPIRATION DATE JOZRMA(3-2-88) OCATION CODE CENSUS TRACT a SUPERVISOM.QISTRICT CODE BUSINESS PLAN FILED DATE FILED �7 2 7 s(d 77 YES NO HECK p PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT p BY: IS 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.