BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNINI WATER RESOURCES CONTROSIOARD ' "F FORM `A': UNDERGROUND STORAGE TANK PROGRAM a SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 NTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE S� I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACI /SITE NAME CARE OF ADDRESS INFORMATION -rr u C t ADDRESS NEAREST CROSS STREET ✓Bam Nuel¢ 0 PARTNERSHIP 0 STATEAGENCY 0CqP MTON 0 LOCAL AGENCY 0 FE)EIULAGDO 0 INDMDUAL 0 COUNTYAGENCY CITY NAME STATE ZI CODE SITE PHONE Al TH APT COD CAsaLSs d - �6� TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PRO ESSOfl ✓Box i(INDIAN EPA ID # ESEF__] 1 GAS STATION F-13 FARM THEA TRUSTYLANDS ATIOND ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE F WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE Al 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 0 PARTNERSHIP 0 STATE-AGENCY ❑ CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toindicate ❑ PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY Cl FEDERALAGENCY 0 INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE p,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. ❑ 11. ❑ 111. 1-:1 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,)S TRUE AND CORRECT, APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY X JURISDICTION N AGENCY F FACILITY IDM S of TANKS S1 SITE " l � 0 CURRENT LOCAL AGENCY FACILITY sto APPROVED BY NAME PHONE N WITH AREA CODE ct 3 PERMIT N MBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE [Cli CATION CODE CENg]]gUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED �/)3 � � �( YES � NO El ECK F PERMIT AMOUNT SURCHARGE AYOU FEE CODE RECEIPT M BY: ITHIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION FORM A(3-2-88) 0