BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIrr WATER RESOURCESCONTR(re-BOARD P E""' FORM `A': °��` ' ��°•�^ UNDERGROUND STORAGE TANK PROGRAM �" SITE /rDFACILITY/SITE, INFORMATION and/or PERMIT APPLICATIONS o COMPLETE THIS FORM FOR EACH FACILITY/SITE `^��.owx�" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION PERMANENTLY CLOSED SITE I"A' ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT El6 TEMPORARY SITE CLOSURE Sd N I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILINISPIE NAM � � CARE Z RESS INFORMATION ADDRESS NEAREST CROSS STjREET) ✓Pmto ❑ STAH AGENIX 61� YCORPOMDON X13 INIMU arvy- CITY NAME STATE ZIP CODE SITE PM NE N,WITH AREA CODE L60r CA q%s,ZLgo TYPEOFBUSINESS: ❑2DISTRIBUTOR F]4�9100ESSOR ✓BO%NINDIAN EPA ID N RESERVATION or ' / F of TANKS /� ❑ 1 GAS STATION ❑3FARM OTHER TRUST LANDS ❑ /IJ ATTHISSTTE 6(/ EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS NAME(LAST,FIRST) PHONE S WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE a&&'L' &' 3 61-"Z_ NIGHTS: NAME LAST,FIRST) PHONE S WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE S II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME _ CARE OF ADDRESS INFORMATION A2 .e MAILING or STREET ADDRESS V Box to indicate PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY FEDERA -AGE I ti ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE ,WITH AREA CODE Cv� r1'zYa Z'0 X69-66 _1 111. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME -ir CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N,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. ❑ it. Ill. ❑ 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 N AGENCY R FACILITY ID S R of TANKS H SITE Db I i -T (/ 7 bo lo 101 CURRENT LOCAL AGENCY FACILITY ID MAPPROVED BY NA E PHONE R WITH AREA CODE C.�ip/z (9 l 4v- /6 8 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT O SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 6 z Z3 .`�U Cf YES NO CHECKS PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTS 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. FORM A(3-2-88) 11110110, DATA PROCESSING COPY `�