BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

or STATE OF CALIFORNI)r WATER RESOURCESCONTROL`60ARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE FMARK,ONLY F-] 1 NEWPERMIT F-13 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE TEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS NEAREST CRO SS STREET ✓Sm bildcYe ❑ PAATNERSHP D STATE AGENCY ❑ caaauna ❑ loco ACF Y ❑ FEDERAL AGE ❑ INDY1WAl ❑ WIINT/�AGEN(,Y CITY NAM STATE ZIP CODE SITE PHONE#,WITH AREA CODE 12 1 N CAS TYPE OF BUSINEs 2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN EPA ID # _ N of TANK# ❑ [DRESERVATION or 1:1AT THIS SITE ❑ 1 GAS STATION [:] 3 FARM E] 5 OTHER EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS', NAME(LRST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Ev MAILING w REET ADDRESS ✓Box to indicate ATIO D D PARTNERSHIP D STATE-AGENCY ❑ CORPORATION LOCAL-AGENCY DFEDERAL-AGENCY C T Ne D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE 19 1 ^.j 6- 53,66 III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING w STREET ADDRESS I ✓Box to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIPCODE PHONE A,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: 1. ❑ if. ❑ 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 8 AGENCY# FACILITY ID R M of TANKS at SITE 3 � I I I TE= CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE#WITH AREA CODE 6�V PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-018TRIC/T CODE BUSINESS PLAN FILED DATE F ED 2 Zb YES E] NO El &I CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTF 8Y: 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. \/\ DRM A(3-2-68) )