BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORA WATER RESOURCES CONTIN BOARD Y� '•A FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE C4llFO lot MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑LM51MANjENTLV CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ /AMENDED PERMIT 'ff6 TEMPORARY SITE CLOSURE D I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME �J ®® CARE OF ADDRESS INFORMATION ADDRESS y�r J_I NErod. ❑ PMREFISHIP ❑ STATEAGDO OUA�GHEl � CY ❑ Rnu-AmlllAI ❑ INMDUAGENCY CITY NAMEG_�p � STATE ZIP COD SITE PHONE N,WITH AREA CODE CA Nf� TYPE OF BUSINESS: ❑2 DISTRIBUTOR ROCESSOfl I ✓Box if INDIAN EPA ID N If of TANK? ❑ ❑ TRUSTAT THIS SITEYLANDS ATION or ❑ i GAS 6TATION [:]3FARM 5 OTHER EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE I` a Ue,, Kkm^ 2/ X73/- 3l NIGHTS: NAME(fAST,FIRST) i PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE II. PROPERTY OWNER INFORMATION &ADDRESS—(MUST BE COMPLETED) NAME �,Y SCv-VIc CARE OF ADDRESS INFORMATION W fvl&I U ri I Q- MAILINGorSTREET ADDRESS I /6 �G�� 1 Ox to iMicale ❑ PARTNERSHIP - 13STATE-AGENCYz�„ 1111CORPORATION LOCAL-AGENCY FEDERAL-AGENCY ❑ INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE 6,;\- roo 2-13-173/3!32- III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to hdicale D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE If,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. 111. ❑ 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 S JURISDICTION B AGENCY B FACILITY IDM N of TANKS N SITE " CIO Z D D D CURRENT LOCAL AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE C'o m" U 51 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO CHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If BY: G,� ✓ �3 ig THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION($), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. , - FO�M A(3-2-8E) 40 \ 1