BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIP WATER RESOURCES CONTRCQOARD o; FORM,`A': UNDERGROUND STORAGE TANK PROGRAM SITEFACILITY/SITE, INFORMATION and/or PERMIT APPLICATION /C_i. COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT F -YCHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5� I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) p FACT ITY/SITE NAME CARE OF ADDRESS INFORMATION t ✓d ce ADDRESS /-' NEAREST CROSS FEET ✓BrIWPlule EJ PARTNERSHIP El STATE AGENCY I� - n-J 13CORPORATION ElLOCALAGENCY 11FEOERALAGENCY a) IS7 ❑ INDIVIDUAL ❑ COUNTRAGENCY O CITY NA STATE ZIP CODE SITE PHONE N,WITH AREA CODE I"a CA SZO3 2r-iii- S TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID a F-11 GASSTATION F-] 3 FARM 5 OTHER TRUSTRESEYLANDS o ❑ Moi HIS SIS v n e� AT THIS SITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME [AST.FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE ft WITH AREA CODE fit/ 6-Lie- NIGHTS NAME(LAST,F ST) /1u PI{pNE ft WITH AREA CODE NIGHTS. NAME(I-AST.FIRST) PHONE 4 WITH AREA CODE 7/// //, / T _20- II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME1 ,A CARE OF ADDRESS INFORMATION ( np� & I SeV✓( MAILING or STREETADDRESS t / ✓Box to intlicate ❑ PARTNERSHIP ❑ STATEAGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STAT ZIP CODE PHONE 4.WITH AREA CODE s n ,I v � Ill. TANK OWNER INF RMATION &ADDRESS — (MUST IME COMPLETED) NAM T ��t CARE OF ADDRESS INFORMATION W/4l d5 MAIUN y;;EETASD'ESS,SeL, ` J-'T- I/Box to intlicate ❑ PARTNERSHIP ElSTATE-AGENCY f � CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY N/VAE--- STATE //t ZIP CODE PHONE k WITH AREA CODE c\J l/tel/-11Y 3 I �l i-jfroS-s�- 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. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTYIN JURISDICTION M AGENCY M FACILITY ID M M of TANKS at SITE CURRENT LOCAL AG-ENCY FACILITY ID M APPROVED BY NAME PHONE M WITH AREA CODE CC PERMIT NUMBER 1 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION/CODE CENSUS TRACT If SUPERVISOR--ODISJT'R�ICT CODE BUSINESS PLAN FILED DATE FILED p O( 2 3 x 9 L/ f�CJ YES E] NO a ?-2�O CHECK M PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT M 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 ONI FORM A(3-2-88) DATA PROCESSING COPY