BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

`/ STATE OFCAUFORMA '1111111110 W.�� s STATE WATER RESOURCES CONTROL BOARD p UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A :m`� ye a r.. o EZ-3 COMPLETE THIS FORM FOR EACH FACILITY/SITE °.�..o.� MARK ONLY F__l T NEW PERMIT O 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED STE ONE ITEM F__j 2 INTERIM PERMIT 4 AMENDED PERMIT Q s TEMPORARY SITE CLOSURE 6 I. FACILITY/SITE INFORMATION III ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR W L• iv!!-� �S ADDRESS NEAREST CROSS STREET PARCEL#(OPrxNIA0 00 l V �G7'DQ At2A 014 C? 1410 -02--a CITY NAI STATE ZIP CODE SITE PHONE s WITH AREA CODE .1 &A-V— CA 525I/ BOX 3 -368- Z88 TOINDICATE O CORPORATION Ems- �AL O PARTNERSHIP aLOCAL-AGENCY OCOUNTY-AGENCY STATE-AGENCY FEDEMLAGENCY DISTRICTS TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR O RE/ IF INDIAN SERVATION #OF TAN,9 AT SITE E.P.A. I.D.#(aptlma) ®3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS Q EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE wiG /LtcS wX 7si0 (2aq) S68-2.88 NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS / ✓ b"bbtlbaM INDIVIDUAL D LOCAL-AGENCY i= STATE-AGENCY 177vtse l .,G(�IJ�{ ' '� Nl CORPORATION = PARTNERSHIP COUNTY-AGENCY =FEDEMLAGENCY CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OW NER CARE OF ADDRESS INFORMATION Lri�Id GiGLG,/!N?S MAILING OR STREET ADDCPs'RES` ltS ` , OW bNakW VIDUAL LOCAL STATE-AGENCY/ O STATE- ENCY o GL A-1 O CORPORATION = PARTNERSHIP O COUNrYAGENCY Q FEDERAL-AGENCY CITY NAME STATE LP CODE PHONE#WITH AREA CODE 1,49.021- 2-E;- Log) IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. TY(TK) HQ 4 4 -1 1 1 1 1 � ] V. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANTS NAME(PRINTEDA SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR LOCAL AGENCY USE ONLY COUN^Y# JURISDICTION# FACILITY# 7 LOCATION CODE -O.�TIONAL CENSUS TRACTS -OP710NAL SUPVISOR-DISTRICT CODE -OP o 75 • 2� 32a E.T s THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA-R2 FORM A(990)