BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORN't WATER RESOURCES CONTRIPBOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑7.PERMA ENILY CLOSED SITE SJ ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE G) N 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) cn FACILITY/SITE NAME CARE OF ADDRESS INFORMATION N N-r (0 M V ADDRESS NEAREST CROSS STREET "too#o 0 PAATNmi? 0 SIATEAGEHA Ary d C�y� C01011 ION 0 LocALAGENv 0 FEDDIALAGENCY WI 0 /i S �/ �� NOMDUAL ❑ COUNTY-AGENCY CITY NAMEs-10 ,&v STATCA ZIP CODESITE PHONE p,Wl� [iEA'C-QE� TYPE OF BUSINESS: ❑2 DISTRIBUTOR F—] 4 PROCESSOR ✓E�SBozd INDIAN EPA ID# �G✓/ If of TANK' 1 GAS STATION ❑3FARM V5 OTHER AT 7RUSTER YLANDS ON or ❑ ATTHISSITE EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAM II S,,T,FIRST)r , PHONE WITH REA CODE AYS: NAME(LAST,FIRST�) ^^__++ ^^ PHONE#WITH AREA CODE VI / B W✓vK NIGHTS: NAME(LASFFIRST) PHONE#(7HAREA ODE NIGHTS: NAME(LASTFIRST) PHONE N WITH AREA CODE L.knn 6 � ol/IIL�•lJ II. PROPERTY OWNER IN ORMATION &ADDRESS — (MUST BE COMPLETED) NAME /� � CARE OF ADDRESS INFORMATION o �oH 1 I,JM MAILING or STREET DDRESS atoindicale ❑ PARTNERSHIP 0 STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY r/V V INDIVIDUAL ❑ COUNTY-AGENCY CITU NAME STATE ZIP CODE 5--Z-01 PHONE#, 'TTH AR�CODE n�U�} 6 fel/ III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME Al _ CARE OF ADDRESS INFORMATION MAILING or STREET AD DRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY l r✓O 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME / STATE ZIP COOE��D/ 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. ❑ II. Ill.❑ 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 Crn�NTY M JURISDICTION B AGENCY# FACILITY ID R #of TANKS at SITE all � � 0 D 02E 16 10 1 / I & CURRENT LOCAL AGENCY FACILITY ID k APPROVED BY NAME PHONE#WITH AREA CODE 1 V 1 a PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCA7 C DE CENSUS ACT# SUPER IS R•DISTRICT CODE BUSINESS PLAN FILED DATE FILED ® 0110123 YES NO CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEECODE 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 0