BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIV WATER RESOURCES CONTROBOARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM u �' S FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �' fo COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 p TLY CLOSED SITE P-A. ONE ITEM E] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT El TEMPORARY SITE CLOSURE —4 I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) IV FACILITY/SITE NAME CARE OF ADDRESS INFORMATION 61 Mi hum ;n ADDRESS NEAREST CROSS STREET ✓Bm Ww&.Ie 0 PARTNERSHIP ❑ STATE AGENCY 3`73 [ CORPORATION 0 LOCALAGENCY 0 FEDERALAGENCr ❑ INDMOUAL 0 COU"ACENCY CITU NAME STATE ZIP E SITE PHONE A,WITH AREA CODE CA D 5 Clio 9 TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box iI IATND IAN EPA ID N ❑ 1 GAS STATION ❑ 3 FARM ❑1 "BOTHER TgUSTVLANDIf of TANIC S 01 ❑ AA � AT HIISSITE LJ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE G ; t'es CA09 4Y8- a P NIGHTS: NAME(LAST,FI ST) PHONE#WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE H WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME<2 ; l CARE OF ADDRESS INFORMATION iPs fi u.�lCi rl- MAILINGorSTREETADDRESS ✓Box to indicate ❑ PARTNERSHIP 13STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY 0 FEDERAL-AGENCY e O 0 INDIVIDUAL 0 COUNTYAGENCY CITY NAME STATE , J 7,PCODE 0 PHONEp,WITH AREA CODE C- K C (/D III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION s 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 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. ❑ if. 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 R JURISDICTION B AGENCY S FACILITY ID 1t N of TANKS at SITE m = = 1010 1 / 17 1 OT-31 10101019 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT SUPERVISOR DISTRICT CODE BUSINESS PLAN FILED DATE FILED 5 9 3. a y YES NO / J CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT BY: 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) 41 DATA PROCESSING COPY