BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNI• WATER RESOURCES CONTROLBOARD FORMA': _- UNDERGROUND STORAGE TANK PROGRAM SITE j �;1 FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �I► COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OFINFORMATION ❑ 7 PERMAN SED SITE ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE fJ� I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) O! FACILITY E NAME CARE QFA jiESS INFORMATION ADDRFFF$$$$$$. 7(•}/VV�(//�-� Y NEAREST CROSS STREET ✓Bodoineicale PARTNERSHIP ❑ SiAiEAGENGY / �J /` ❑ fpAPOPHiION LO'ALAGENCY ❑ FEDEAPLAGENCY / / C i"NDIVIDUAL ❑ CDUNOAGENCY CITY NAM F.� �. � f �4 STATE ZIP CODE�� SITE RHO 0, I� E �D� TYPE OF BUSINESS.•'v❑r-'/KjJ'-T/R"IB,UTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID uRESERVA // 5 ��'J a~✓`)J#of TANK's Q/ ❑ 1 GASSTATION 3FARM ❑ 5OTHEA TRUST LATNDSION o ❑ A1/A ATTHISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYq NAME ST) A PHONE 14ITH AREA CODE DAYS. NAME( AST,FIRST) PHr WITH AREA CODE 974 NIGHTS'. NAM L. IRST) PHONE (/)TH AREA CODE NIGHTS: NgpA�qJAST,FIRST) PHOX71TH AREA CODE If. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BECOMPLETED) NAME '51A CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL AGENCY ❑ INDIVIDUAL ❑ COUNTYAGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME u/� CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS 1/80.to indicate ❑ PARTNERSHIP Cl STATE-AGENCY ❑ CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ 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. Ef� !I. ❑ 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&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE 3 � d 0 v 6 poo I I CURRENT LOCAL AGENCY FACILITY ID# APPR V D BPHONE#WITH AREA CODE Y PERMIT NUMBER PERTaIJ APPROVAL DATE I-EhAIT EXPIRATION DATE LOCAT CODE CENS S TRACT# "j/`•/ SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 11 �7, Z�- YES ❑ N L CHECK# PERMIT AMOUNT SURCHARGE 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. D A(3-2-88) A DATA PROCESSING COPY