BILLING - Laserfiche WebLink

Home Browse Search

oT... STATE OF CALIFORNIA WATER RESOURCES CONTRO OARD FORM 'A': UNDERGROUND STORAGE TANK PROGRAM �o SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EAC FACILITY/SITE MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE ONE ITEM ❑2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION !c Gtw' / Pllailw ADDRESS / NEAREST CROSS STREET ✓9,vbrecti O PARTNERSHIP O STATE AGENCY ❑ CORPMATION ❑ LOCAL.AGE10 ❑ FEDERAL AMU ❑ INDIVIDUAL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE p,WITH AREA CODE — CA TYPE OF BUSINESS'. ❑ ISTRIBIITOR ❑ d PROCESSOR '/Box if INDIAN EPA IDN of TANK Y ❑ 1 GAS STATION 3 FARM ❑ 5 OTHER RESERVATION or F-1ATTHIS SITE TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE ce e 201- 446- 703( NIGHTS: NAME4UST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE p/of"e yellilld ZGr .(S- • b R 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Be.toindicate ❑ PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE F.WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to indicate O PARTNERSHIP ❑ STATE-AGENCY ❑ CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl 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. ❑ if. ❑ 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 8 SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY F JURISDICTION N AGENCY* F of TANKS At SITE " 4 IequpRgk1 T LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHONE F WITH AREA CODE e PERMI DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUSTRACTF SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED DATE FIVE) . Z YES NO r 6K N' PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT If 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. ^ ` FORMA(3-2-88)