BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL ARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM "I SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �I I COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT Dr5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED S E F-A ONE ITEM ❑ 21NTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE W I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) pip FACILITY/SITE NAME �y CARE OF ADDRESS INFORMATION m i s s i o n L7TCc1L4, ADDRESS //�-� NEAREST CROSS STREET ✓3RKrnoB ❑ 'WNDOW [,I 5TAII!,V,Ev.Y o a I n w "1 Cl "0X Cl �� Cl ImEPel.udcY CITY NAME STATE ZIP CODE SITE PHONE 4,WITH AREA CODE CA TYPE OF BUSINESS. ❑ 7 DISTRIBUTOR ❑ 3 PROCESSOR ✓80.4 INDIAN EPA 10 4 RESERVATION or AT HIS SI ❑ I GAS STATION ❑ 3 FARM 5 TANKs OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: .NAME(LAST.FIRST) PHONE 4 WITH AREA CODE DAYS. NAME;LAST.FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS. NAME IL1ST.FIRST) PHONE 4 WITH AREA CODE II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓80.to matcate ❑ PARTNERSHIP ❑ STATE-AGENCY Cl CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl 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 ✓Box to'rotate ❑ PARTNERSHIP ❑ STATE-AGENCY Cl CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY Cl INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,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: I. ❑ if. ❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT NAME(PRINTED 6 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY K JURISDICTION• AGENCY k FACILITY ID A 8 of TANKS At SITE OU 1 L o0 c c) CURRENT LOCAL AGENCY FACILITY 10 4 APPROVED BY NAME PHONE 4 WITH ARG CODE miss I i c PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION COD[ CEX3US TRACT I SUPERVISOR-DISTRICT CODE BUSINESS PLAN❑FILED NO ❑ OPS(« C) � a� ( I CHECK F PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT 4 BY: / JTHIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ON' 41ORM A(3-7410) --- DATA PROCESSING COPY ,,,,�