BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORMW: { UNDERGROUND STORAGE TANK PROGRAM =� Z SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION to COMPLETE THIS FORM FOR EACH FACT Y/SITE =`- MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY LOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 1 0 1. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION I ADDRESS •� NEAREST CROSSSTREET ✓Br YNicale ❑ PARTNEASNIP ❑ STATE AGi ❑ OA PATION [ILOCAL#GENLY ❑ FEDERnI-AGENCY ❑ INDIVIDUAL ❑ 000NIP-AGENCY CITY NAME STATE ZIP CODE SITE PHONE*.WITH AREA CODE TYPEOFBUSINESB EPA DAIt ❑ 2 D6TRIBUTOR ❑ 4 PROCESSOR ✓Boz if INDIAN #of TANK'* RESE ❑ 1 GAS STATION [:] 3 FARM ❑ 5 OTHER TRUSTYLANDS o ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST,FIRST) PHONE*WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE 111. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. ❑ it ❑ 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» AGENCY# FACILITY ID N N of TANKS at SITE m = = O01/'Z33 d 10 111 CURRENT LOCA ENCY FACILITY ID M APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMINVIR PERMIT APPROVAL DATEPERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED DATE FILED VES [—] NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT* Y: 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. FORMA(3-2-88) \/ DATA PROCESSING COPY _0