BILLING - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIA'`' WATER RESOURCES CONTROL BOARD .s1 4 FORM `A': UNDERGROUND STORAGE TANK PROGRAM � al0 Z SITE l o FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �, FORu COMPLETE THIS FORM FOR EACH CILITY/SITE 1 NEW PERMIT ❑3 RENEWAL PERMST 5 CHANGE OF I:FORMATION �07 �TYCLOIEDS�ITI [MEARK:ITEM Y ❑ '� ❑2 INTERIMPERMIT ❑4 AMENDEDPERMIT ❑6 TEMPORARY Cw 1. FACILITY/SITE INFORMATION & ADDRESS- (MUST BE COMPLETED) ` CARE OF ADDRESS INFORMATION FACILITY/SITE NAME • S NEAREST CROSS STREET xtomdrate ❑ PARTNERSHIP ❑ STATE-AGENCY ADDRESS r + n� �If �J GORPORASION ❑ LOCAL-AGENCY C3 FEDERAL-AGENCY ❑ IN011'IpI7AL ❑ COUNIY-AGENCY , 1 STATE ZIP CODE SITS F�-{pNE#.WITH AREA CODE CITY NAME L+A )/,J•J Uy/� TYPE OF BUSINESS' 2 RIBl1TOF ❑ 4 PROCESSOR ✓8ox ii INDIAN ❑ EPA ID # 8 of TANK' ❑ RESERVATION or AT THIS SITE ❑ 1 GAS STATIONLz FARM ❑ 5 OTHER TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE R WITH AREA CODE DAYS: NAME(LAST,FIRST} UPHONE#WITH AREA CODE NIGHTS: NAMES .FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST.FIRST) 11. PROPERTY OWNER INFORMATION &ADDRESS MUST BE COMPLETED) rNAME 4 CARE Of ADDRESS INFORMATION STREET ADDRESS !1_ ex to indicate ❑ PARTNERSHIP ❑ STATE- GENCY L-AGEN/y _�� CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY /`�Z/LJ ! C3 INDIVIDUAL ❑ COUNTY-AGENCY E STATE ZIP CODE PHONE#.WITH APEA IN. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) NAMEsn CAREOFADDRESSINFORMATION GCf ' ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY MAILING or STREET ADDRESS ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL ❑ COUNTY-AGENCY STATE ZIP CODE PHONE#,WITH AREA CODE CITY NAME I . LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(7)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FON BOTH LEGAL NOTIFICATION AND SICCING: I. II. ❑ III.■ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. v APPOCANT'S NAME(PAINTED&SIGNATURE) DATE ✓I LOCAL AGENCY USE ONLY COUNTY IF JURISDICTION N AGENCY IF FACILITY ID S N 01 TANKS at SITE [m] vv l 0101 q v CURRENT LOq*L AGENCY FA�kI,y�Y 1L2 N APPROVED BY NAME PHONE N WITH AREA CODE PERMIT NUMBER L 'r/1'�ffjU PERMIT APPROVAL DATE PERMIT EXPIRATION DATE 40CAT N CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 9 Z Z YES ❑ NO .—�� HECK N PERMIT AMOUNT SURCNA GE AMOUNT FEE CODE RECEIPT N BY: _ ^ ' IS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ON A(3-2-88) I DATA PROCESSING COPY I