BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL JOARD :5` `°.. FORM `A': UNDERGROUND STORAGE TANK PROGRAM a SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION 40 COMPLETE THIS FORM FOR EACH FACILITY/SITE <�=ons`" MARK ONLY F-1 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYCLOSED SITE I-J ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE N I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) FACI ITV/SITE NAME CARE OF ADDRESS INFORMATION N o ADDP(�EJS�S \ T NEAREST CROSS STREET yyy�� ✓ rdrsk PARTNERSHIP ❑ STATE AGENCY L A V R Ch D Ke��cQl ❑ IND WCORPORAL� ❑ COUNTY�EB�i ❑ FEDERAL-AGFNCV CIN NAME t vT �..I STATE 21P CODE D SITE PHONE N,WITH AREA CODE TYPE OF BUSINESS: ❑2 DISRIIBUTOR ❑ 4PROCESSOR '/BOX if INDIAN EPA ID # ��IO ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUSTYATION LANDS or ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAY NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE erao NIGHTS N ME(I-AST, PH ST,FIR E#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE IL PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION to iG�tCt�( Y) eV` MAILING or STREET ADDRESS ✓ """=to ❑ PARTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY A D INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME I STATE ZIP CODE PHONE p,WITH AREA CODE IDL III. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAME ,' as CARE OF ADDRESS INFORMATION co MAILING or STREET ADDRESS ✓Boz to mdIC.I. ❑ PARTNERSHIP 13STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,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. ❑ II. III. 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 = = = 00l7 -1-1 0063 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE CQ iV F_ to PERMIT NUMBE4 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOC TION CODE CENSUS TRA SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED H'Y1 3,�U a YES NO CXECKM PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN Y: / THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. 1. 1 FORM A(3-2-BS) �I IIWP/ DATA PROCESSING COPY