BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM ' b" SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ° : o COMPLETE THIS FORM FOR EACH ACILITY/SITE `'"•aan`" MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 155 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS TE 1' ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE -4 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W FACILITY/SITE,NAME CARE OF ADDRESS INFORMATION # ��//,V// ADO �y�(,/ /T /� // NEAREST CROSS STREET car 11 PARNBBIP ❑ STATE AGENCY no' 11 LOCALAGDRFEDERAL AGENCY/DUAL ❑ WUNWANp CITY NAME STATE ZIP CODE S SITE PHONE p,WITH AREA CODE a CA 6 TYPE OF BUSINESS: 2 ISTRIBUTOR ❑ 4 PROCESSOR RESERVATION if INDIAN Dr EPA ID N If of TANK'# ❑ 1 GAS STATION V3 FARM ❑ 5OTHER TRUST LANDS ❑ AT THIS SIT- EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION ag 1 MAILING or STREET ADDRESS ✓Boz to indicate D PARTNERSHIP D STATE-AGENCY D CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) N CARE OF ADDRESS INFORMATION �s MAILING or STREET ADDRESS ✓Box to indicate D PARTNERSHIP D STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY D INDIVIDUAL D 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. it. ❑ 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 A,SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY k JURISDICTION S AGENCY S FACILITY ID If #of TANKS SL SITE [a] I I I WaKm 1 o 10 101 XI— CURRENT LOCAL AGENCY FA�LITY IDJI APPROVED BY NAME PHONE#WITH AREA CODE PERMIT 1110ER If/ (I PERMIT APPROVAL DATE PERMIT EXPIRATION DATE PCHEC N CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIEP 2 YES NO ❑ PERMIT AMOUNT SURCHAR E 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." FORM A(3-2-88) DATA PROCESSING COPY