BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD w�v �s9 FORM 'A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ly-I sc COMPLETE THIS FORM FOR EACH FACILITY/SITE �^"F_r_--' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 6 ty 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) to FACILITY/SITE NAME CARE OF ADDRESS INFORMATION n erstmcc ADDRESS /^D NE REST CROSS STREET %/Box to indrsle Cl PARTNERSHIP ❑ SiAiEAGENCY / d n ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATCA PDE._ SITE PHONE kAREA CODE �o TYPE OF BUSINESS ❑ 2 ISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID p �J Jj`(-^' 3 RESERVATION or It of TANK's ❑ 1 GAS STATION LQ43 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE#WITH AREA CODE nets J ^o - -3`/170 NIGHTS: NAME(LAST,FI T) PHONE#WITH AREA CODE NIGHTS: NAME(LAST FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAIL— DARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to ord,cate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAM CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box W old,cate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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. 1 1 If. ❑ 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 If AGENCY# FACILITY ID# It of TANKS at SITE os 1 CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE a6 �5 5 PERMIT NU BER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA Iw CODE CENSUS TR�A7CT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE F LED 1 Z3 '��—� YES NO 26/ CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: THIS FORM MUST BE ACCOMPANIED BY AT a LEAST 1R MORE TANK PERMIT FORM 'B'APPLICATION(S), UNj�SS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA(3-2-SS) _ ^ R)CI DATA PROCESSING COPY