BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN* WATER RESOURCES CONTRZ7C BOARD y4rl FORM `A': UNDERGROUND STORAGE TANK PROGRAM y SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION m �� o COMPLETE THIS FORM FOR EACH FACILITY/SITE `+i,.on�rr• MARK ONLY ❑ 1 NEW PERMIT El 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM p INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE w I. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) �C71 FACILITY/SITE NAME v CARE OF ADDRESS INFORMATION YIF�t'' Y Or 4 }�'ot-� ADDRESS ,Sy NEAREST C'gp,+G�S STREET ✓g0C:"xak ❑ BINBEHN ❑ STRTE-AGEC J M O j,�(YR +'Ch- 1 1 C� O I OMD TION UAL ❑ COUNTY AGENCY ❑ FEDERAL AGENCY CITY NAME STATE 111' ZIP ODE SITE PHONE a, WITH AREA CODE S+ kl , cA s�oa ao4G1q , TYPE OF BUSINESS: E__12 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID a Ej i GAS STATION 0 3 FARM 5 OTHER RESERVATION or ❑ N of TANK4 O TRUST LANDS AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION 81 ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION v IA— MAILING or STREET ADDRESS �✓ inalcate 13 PARTNERSHIP ❑ STATE-AGENCY S ✓l 1 -LTCORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY 1 / 1 ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STAT CODE PHONE a,WITH AREA CODE kl--N � ZIPCODE s )_6;�L_ III. 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 Jr.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: I. 0 If. it ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME)PRINTED It SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY K /, FACILITY ID N k o/TANKS BI SITE S�ll O U 1 ( \ O V CURRENT LOCAL AGENCY FACILITY 10 N SToL APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIO�CODE CENSUS TRACT N SUPE RVI l 1$TRICT CODE BUSINESS PUN FILED DATE FILED VES NO ❑ l .Yo6_j CHECKN PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `S'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-88) N..W DATA PROCESSING COPY ./