BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

a .:... ....'�fl1Y_ '•dY$,qaA, �.._t � _ . . ,: ,.y. _... , y.,,�.�a. ,�T�ny STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o SIT FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH F ILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMA LOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE ' #Q I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION �SCIr �L •0'0• ADDRE NEARSSTCROSSSTREET ✓BN.blgo ❑ PPAINE0.RYP 0 STATEAGEN(Y W' ` (�(Q.t/I�/� ❑ crolmrnanori ❑ LocuAGB+cY ❑ ED L.AGEr+cr ❑ INED[Jk 0 I:GGNn AGBICY CITY NAME / V c �l STATE ZI D� SI7p�N1� ,WITH AREA CO E� TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box i'INDIAN EPA ID N r-1I GAS STATION F-13FARM BOTHER RESERVATION YS or ❑ MUE TANK's AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS'. NAME(I-AST.FIRST) PHONE N WITH AREA CODE V. 1 NIGHT :NIGHTIJJ NAME KAST,FIRST) PHONE N WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE s cxr� II. PROPERTY OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAM-E _ CARE OF ADDRESS INFORMATION MAILING(jor-STREET ADDREU ✓Box to irldicrle ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY / / 13 :7 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PH NE A.WITH AREA CODE 501b 1 a - a III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME DARE OF ADDRESS INFORMATION MAILING or STREET AbDRESS ✓Box to mclicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCALAGENCY0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIPCODE 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. ❑ 11-VIII. ❑ 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 A JURISDICTION# AGENCY# FACILITY ID# 11 of TANKS at SITE CURRENT OCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE Shah,'�-o b 3— PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 't 01 �3. 0 D �� :,-L, YES [—] NO ❑ l r �9 CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTBT: MENOMONEE 11 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. 1� f FORM A(3-2-BB) ,ry� - 0 iy / � DATA PROCESSING COPY