BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIP WATER RESOURCES CONTRIBOARD e FORM 'A': UNDERGROUND STORAGE TANK PROGRAM o21 SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - T so COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY F-1jAEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 1 P NTLY CLOSED SITE ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) N FACILITY/SITE W j O CARE OF ADDRESS INFORMATION H9e )e p red NEAREST CROSS STREET IOiMiGBIe Cl PARTNERSHIP ❑ STATE-AGENCY ADDRESS b M I I /� GDRPORATIDN '❑ LOCALAGENCY ❑ FEDERAL-AGENCY 3 V ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME f/ Com/// STATEfil ZIP CODE SITE PH11.WITI�AAAA COD �d TYPE OF BUSINESS: ❑ p DISTRIBUTOR ✓(4 PGCESSOR ✓Box if INDIAN EPA ID # �t 7jy/r/n •j(/n rQg of TAAANN(KKs OQ ❑ I GAS STATION ❑ 3 FARM 5 OTHER TRUST�LANDS ESEATIONof 1:1 IF AT THIS SITE EMERGENCY CONTACT PERSON(PRIMAR ) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIR � � Ar 0 PHONE N WITH REA CODE DAYS: NAME(LAST,F RST) PHONE p WITH AREA CODE /—, -- 92,E _OO r NIG S: NAME(LAST RST) PHONE#WITH AREA CODE NIGHTS: AME(LAST,FIRST) PHONE It WITH AREA CODE 5 - s IL PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME � CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESSx to indicate 13 PARTNERSHIP ❑ STATE-AGENCY CORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY INDIVIDUAL ❑ COUNTY-AGENCY CITY"NAME STATE ZIP CODE PHONE 4,WITH AREA CODE III. TANK OWNER_ INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS - ox to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY d � 'ef��/ •'' OCCIPOR'TI ON ❑ LOCAL-AGENOY ElFEDERAL-AGENCY INPr. jDIVIDUAL ❑ COUNTY-AGENCY &Y NAME STATE ZIP CODE PHONE#,WITH AREA CODE � 7� �j3`Z� ZB l� C/o 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. ❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KN0WLEDGE, IS TRUE AND CORRE�T. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY FPERMITNUMBER JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE FT 10101 / 41-rd d OE2 AGENCY FACILITY IDN APPROVED BY NA PHONE N WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPI TION DATE ZZo CENSUSTRACTN SUPERYI OR-DISTR CT CODE BUSINESS PLAN FILEDDATE FILED YES 0 NO 67 PERMIT AMOUNT) SURCHARGE AMOUNT7�� RECEIPT N BT: THIS FORM(RUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-88) DATA PROCESSING COPY