BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFOkNIA WATER RESOURCES COkTfiOL BOARD �—oF �.ycP`.. ry •'aw f FORM `A': ,. UNDERGROUND STORAGE TANK PROGRAM "°o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , 1O r� I COMPLETE THIS FORM FOR EA H FACILITY/SITE "LIFIRN P MARK ONLY T NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PE CLOSED ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSUREILI a) I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACIL TY/SITE NAYIE /��A/ ' I QAFIE OF ADDRE INFORMATION I •I /V ADDRESS . //^ NEAREST CROSS STREET ✓Box to rtRATIO ❑ PARTNERSHIP ❑ STATE-AGENCYC ❑ CORPORATION ❑ LOCAL-AGENCY ERAL ENCS' ❑ INDIVIDUAL ❑ COUNTYAGENCY IV CITY N ME � STATCA ZIE CQ�E SITE ONJ��WITH AREA ODE CITY TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ k of TANK's .PROCESSOR ✓Box if INDIAN EPA ID # C'S sy RESERVATION or ❑ i GAS STATION ❑ 3 FARM 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: E(LAST,FIRST) PH14E#WITH AREA CODE K- 6,111los 367--2s/A NI TS. NAME( ST.FIRST) PHONE#WITH AREA CODE NIGHTS NAME(LAST,FIRST) VH NE#WITH AREA CODE UA m II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME ��. CARE OF DRESS INFORMATION C 1,� MAILINQ o STREET ESSA ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY ElCORPORATION ❑ LOCAL-AGENCY DEQ RgL-AGENCY 11INDIVIDUAL ElCOUNTY-AGENCY (1{ 12) CITY NFA,; � � STAZE� ZIP CODE � PHONE �H AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME v CARE OF D RESS INFORMATION 0 /A MAII,JpL:Z)TR ET ADDRESS V1Boxto indicate ❑ PARTNERSHIP ❑ ST -AGENCY rrVJ UU ❑ CORPORATION ❑ LOCAL-AGENCYERAL GENCY El INDIVIDUAL ❑ COUNTY-AGENCY CITY NA STATE ZIP CODE PHONE ITH 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. ❑ II. ❑ 111. 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# #of TANKS at SITE Lv I o le� CURRENT LOCAL FACIL N A�OV�D BY N/ME a PHONE#WITH AREA CODE (/. C-- [Jl Iv7. �1 PERMIT NUMBER PERMIT 4PPpOVAL AT PERMIT EXPIRATION DATE llyl-10-e LOCATIQN CODE CENSUS TRACT# SUP V OR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO GA CHECK# PERMIT AMOUNT SURC AR AMOUNT FF�ODE RECEIPT# BY: 1 77 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