BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIft WATER RESOURCES CONTRO RD FORM `A': UNDERGROUND STORAGE TANK PROGRAM 0 Z SITE �� FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE,THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ Y LOBED SITE N ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE b t/ 00 I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) W FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ADDRESS ' NEAREST CROSS STREET Bu bbEirsk PAIiINEPSIIP ❑ SIATEAGENLY 97 D VV t �� ❑ MWOUATION ❑ LOUNTY AGENCY ❑ FEDE0.LL AGENLY `6 ❑ INOMOUAI Cl COUNIYAGENLY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK'# ❑ I GAS STATION ❑ 3 FARM OTHEA TRRUST LANDS ATIONor ❑ 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 II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ElPARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTY-AGENICV CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to inc nate ❑ PARTNERSHIP D STATE-AGENCY Cl 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(t)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ Ill.❑ 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# JURISDICTION# AGENCY# FACILITY ID It #of TANKS at SITE 6 CURRENT LOCAL AGENCY FACILITY ID pt APPROVED BY NAME PHONE#WITH AREA CODE PERMIT NUMBER //J` PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCAT177E CENSUS TNA M OR CODE BUSINESS PUN FILED DATE FILE � ' �j Z UP 3 C— YES NO ❑ CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPA IE BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY,V./Y F RMA(3-2-88) tl \Q�\\1 \ I ' DATA PROCESSING COPY i !1