BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTR'CCBOARD FORM'A':/ UNDERGROUND STORAGE TANK PROGRAM k! SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION N COMPLETE THIS FORM FOR EACH ACILITY/SITE U MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT DZ5 CHANGE OF INFORMATION ❑ 7 PER LOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT [:]6 TEMPORARY SITE CLOSURE AW I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME j q /V'-1 CARE OF ADDRESS INFORMATION NAME We CARE OF ADDRESS INFORMATION ADDRESS NEAREST CROSS STREET ✓Aa IPD6AtIDN D LOMASNIP C STATE-FEDPAC¢NDY ❑ LOG44AGENCI ❑ Fl:DFIVLAGBIp / D INDIVIDUAL D COUNTYAGENCY wDNIDU& D CDUNIY AGB# CITU NAMEIF � STATCA ZIP CODE. SITE PHO#=N, WITH AREA�%E 9S yf FEE CODE STATE TYPE OF BUSINESS: ❑ 23IBUTOR ❑5 PHONE #. WITH AREA CODE EPA ID p # of TANK'# OROCRSSOR 1:11 GAS STATION FARM E:AT RUSTYLANDS dr ❑ THIS SITE EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) # WITH AREA DAYS: NAME (LAST, FIRST)�� DAYS'. NAME (LAST, FIRST) PHONE X WITH AREA CODE �G �PHONE /CO' 4 G NIGHTS: NAME (LAST. FIRST) I PHONE N WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE N WITH AREA CODE n w�iure wzn^n"ArInW & AnnoS=CS — IMI IST RF COMPLETEOI rnvr�ri • - NAME CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFORMATION V ✓ Bon to indicate D PARTNERSHIP C STATE -AGENCY MAILING or STREET ADDRESS D CORPORATION C LOCAL -AGENCY D FEDERAL -AGENCY LOCATION OQE, !4/ D INDIVIDUAL D COUNTYAGENCY CIN NAME STATE ZIP CODE PHONE N, WITH AREA CODE III• TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) IV. LEGAL NOTIFICATION AND BILLING ADDRESS `CHECK ONE (1) BOX INDICATING WHICH ASOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. Ev1l. ❑ 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 B SIGNATURE) DATE A/]cm^v "CC nui V COUNTY N JURISDICTION N AGENCY N �10 FACILITY ID N N of TANKS Bt SITE 10 (R b 10 11 CURRENT LOCA AGENC NK/ r 9C�l��/ NAME CARE OF ADDRESS INFORMATION V N PERMIT EXPIRATION DATE LOCATION OQE, !4/ ✓ Box to indicate C PARTNERSHIP C STATE -AGENCY MAILING or STREET ADDRESS BUSINESS PLAN FILED YES NO � D CORPORATION C LOCAL -AGENCY D FEDERAL -AGENCY CHECK# PERMIT AMOUNT D INDIVIDUAL D COUNTY -AGENCY FEE CODE STATE ZIP CODE PHONE #. WITH AREA CODE CITY NAME IV. LEGAL NOTIFICATION AND BILLING ADDRESS `CHECK ONE (1) BOX INDICATING WHICH ASOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. Ev1l. ❑ 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 B SIGNATURE) DATE A/]cm^v "CC nui V COUNTY N JURISDICTION N AGENCY N �10 FACILITY ID N N of TANKS Bt SITE 10 (R b 10 11 CURRENT LOCA AGENC NK/ r 9C�l��/ APPROVED BY NAME PHONE#WIT#AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION OQE, !4/ CEN8US TRACT N 2 SUPERVISOR-DI8SRICT CODE BUSINESS PLAN FILED YES NO � DATE FILED p ,6— zr0 CHECK# PERMIT AMOUNT SURCH GE AMOUNT FEE CODE RECEIPT# BY: L/✓ THIS FORM MUST BE ACCOMPANIED BY AT LEAST 11) OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORM A (3-2-88) �,. A� DATA PROCESSING COPY Il/ mt, N N co