BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN19 WATER RESOURCES CONTROBOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAMo SITE ,7�_. FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ; ao COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION P� / PERMANENTLY CLOSED SITE 1"+ I ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE d I. FACILITY/SITE INFORMATION & ADDRESS— (MUST BE COMPLETED) w A FACILITY/SITE NAM CARE OF ADDRESS INFORMAT ON 1 ADDRESS I I r�-T1 a� NEAREST CROSS STREET ✓govmimi TIO ❑ LOCALAGEN ❑ FEDERAGENCY f )ROSSS REE n\ ❑ APOAATION ❑ LOCALAGFNC/ Cl FEDTE AGENNCY INDIVIDUAL ❑ COUNTY AGENCY CITY NAM nn STATE O j_E SITE ONE p,WITH AREA CO �S,L.,Y o nr Z CA t 9 3 ox TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it INDIAN EPA ID # ❑ It of TANK's 1 GASSTATION [:]3 FARM -POTHER TRUSTYLANDS ATION Gr 1:1 "�— ATT IS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME LAST,FIRST) PHONE#WITH AflEA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE r ' foll M NIGHTS: NAME(I.A5T,FIRST) — — n PHO[�N,E#WITH AREA �CCODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE M_u) t� r Y 0 1 .�2r�N 11. PROPERTY OW ER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARL OF ADDRESS INFORMATION G MAILIN47 EET ADD 5 C ✓Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY 12CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY -E}-WDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE S 3a e 0 3)%_ i 111. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION vY`s c MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE 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.,�/VIII. ❑ 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 As AGENCY# FACILITY ID# #of TANKS at SITE I a0 I U CURRENT LOCA AENCY FACILITY IID# APPROVED BY NAME PHONE#WITH AREA COO I PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L DE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED Iq 2 YES ❑ NO 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) • DATA PROCESSING COPY •